CLF HelpLine

Contact Information

Please fill out your information. You will be the main point of contact for this HelpLine request.

First Name

Last Name

Country

Address

If different than patient - please provide patient zip code in "other relevant info" box

City

State/Province

Use abbreviated state name (Ex. New York = NY)

Postal Code

Phone Number

Email

Confirm Email

What is your preferred method to be contacted?

Phone appointments are available in the US and Canada. Please follow the instructions in your confirmation message on the next page.

Patient Information

This section asks about the patient and their history of brain trauma exposure. Complete this section to the best of your ability regarding your knowledge of the patient's brain injury history.

Are you looking for help for yourself or a loved one?

The loved one is my...

Child, Spouse, Friend, etc.

Patient City

Patient State/Province

Patient Year of Birth (YYYY)

We ask for age because some medical providers have min/max requirements

Patient Sex

Patient Race

Patient Military Service

Patient Military Branch

Patient Military Status - Pre or Post 9/11?

If your service ENDED before 9/11/2001, select "Pre 9/11"

Do you feel you or the patient is experiencing a crisis? Please rate the level of crisis from 1-5, with 1 being "not in crisis" and 5 being "in active emergency".

DISCLAIMER: This is not a crisis helpline, however we can direct you to crisis-related resources

Which of the following selections best captures your reason for reaching out?

A recent concussion/mTBIPersistent Post-Concussion Symptoms (PPCS)Suspected Chronic Traumatic Encephalopathy (CTE) symptomsEnrolling in clinical researchOther

If you selected other, what are you looking for help with?

Which of the following options would be most helpful to meet your needs?

Medical or mental health provider recommendations near the patientConnection with peer supportInformation about symptomsInformation about treatmentsInformation about clinical researchOther

Please estimate the patient’s number of concussions (diagnosed or not).

When did the patient’s most recent brain injury occur?

Please estimate the patient’s number of years of exposure to Repeat Head Impact (RHI) from sources such as contact sports, military service, intimate partner or domestic violence, etc.

Please list the sources of concussion and/or exposure to Repeat Head Impact (RHI).

i.e. history of injury to the brain

What symptoms is the patient currently experiencing?

What doctor has the patient already seen? Check all that apply:

The patient hasn't seen a doctorThe patient has seen their primary care physicianThe patient has seen one specialistThe patient has seen multiple specialists

If the patient has seen multiple specialists, please list them:

What treatments has the patient tried?

If no treatment was tried, why?

Is there any other relevant information you would like to share with us?

Referral Information

What college or university do you feel most connected to?

This could be where you attended, graduated, work, or have another connection. We ask this because some alumni networks offer support and resources.

How did you hear about us?

If you selected other, how did you hear about us?

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Contact Information