Services Application

Services Application

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Apply for our Services

There is no cost to the individual for Case Management services.

Anyone can refer an individual to our program; however, the individual must want services and enroll in the program. Contact our office for more information at info@bicsv.org or call 540.568.8923

To apply for our services, please fill out or download the form below

Download English services application | Descargar aplicación de servicios en español

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Primary Phone *

Other Phone

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Legal Representative

Do you have a legal representative? *

Name of Legal Representative *

Relationship to Legal Representative *

Please attach/submit legal representation documentation.

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

What is the best method for contacting the applicant and/or legal representative(s) or caregiver? *

Provide name and contact information if not stated above.

Brain Injury Information

Date of Injury *

Cause of Injury *

Briefly describe the issues you may be having as a result of your brain injury, including what help you may need *

Which of the following evaluations have you had completed? (Please provide a copy and name of the provider): *

Neurological
Neuropsychological
Psychological / Psychiatric
Therapy (Physical, Occupational, Speech)
Other

If other, please specify

Please state the name of the provider

Please provide a copy of completed evaluations

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

If attending school, do you (client) have a(n)

IEP
504 Plan

If you do please provide a copy of the plan.

Drag & Drop Files, Choose Files to Upload

How did you hear about us? *

Community Agency
Brochure
Department for Aging and Rehabilitative Services (DARS)
Word of mouth from friend or family member
Community event or presentation
Internet / Website
Brain Injury Assoc. of Virginia (BIAV)
Physician
Other

If other, please specify *

I am the applicant and I would like services from Brain Injury Connections of the Shenandoah Valley.
I am applying on behalf of another individual as his/her legal representative. The individual (applicant) is aware that this application is being submitted on his/her behalf and desires services.

Name of person completing the application *

First

Last

Company/Organization *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Relationship to Applicant *

Signature of Legal Representative *

Clear Signature

Signature of Applicant *

Clear Signature

** Note: If you are a provider working for another community agency or organization and submitting this application on behalf of another individual, the individual must sign above as applicant (unless you are a legal representative), please obtain consent and include any relevant medical or other documentation with this application. You may fax records to (540) 568-8864.

Date *

JMU Campbell Building,
755 Martin Luther King Junior Way,
Harrisonburg, VA 22801

Quick Links

What We Do
Service Area
Support Groups

Contact

Phone: (540) 568-8923
Fax: (540) 492-5587
Email: info@bicsv.org

Hours of Operation

Monday to Friday:
8:00am – 4:00pm

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