Use abbreviated state name (Ex. New York = NY)
What is the best way to contact you?
American Indian or Alaska Native
Black or African American
Native Hawaiian and Pacific Islander
Some Other Race
Date of Birth (MM/DD/YYYY)
Military Status - Pre or Post 9/11?
If your service ENDED before 9/11/2001, select "Pre 9/11"
Help Request Information
This section asks about the patient's history of brain trauma exposure. Complete this section to the best of your ability regarding your knowledge of the patient's brain injury history.
Do you feel you or a loved one are experiencing a crisis? Please rate your level of crisis from 1-5, with 1 being "not in crisis" and 5 being "in active emergency".
Prefer not to answer
DISCLAIMER: This is not a crisis helpline, however we can direct you to crisis-related resources
What are you looking for help with?
A recent concussion
Enrolling in clinical research studies
Lingering concussion symptoms, or Post-Concussion Syndrome (PCS)
Symptoms that may be related to Chronic Traumatic Encephalopathy (CTE)
If you selected other, what are you looking for help with?
Are you looking for help for yourself or a loved one?
If a loved one, what is your relationship to them?
What exposure have you or your loved one had to brain trauma?
What symptoms are you or your loved one currently experiencing?
What doctor have you or your loved one already seen? Check all that apply:
I haven't seen a doctor
I have seen my primary care physician
I have seen one specialist
I have seen multiple specialists
If you have seen multiple specialists, please list them:
What treatments have you or your loved one tried?
If no treatment was tried, why?
When did your last brain injury occur?
Within a month
1-6 months ago
7-12 months ago
1-2 years ago
2-5 years ago
5-10 years ago
10+ years ago
Is there any other relevant information you would like to share with us?
How did you hear about us?
If you selected other, how did you hear about us?