7305 Grand River, Suite 100 | Brighton, MI 48114-7379 Office (810) 229-5880 | Fax: (810) 229-8947 Helpline: 1-800-444-6443 E-mail: info@biami.org | Website: www.biami.org 7305 Grand River, Suite 100 | Brighton, MI 48114-7379 Office (810) 229-5880 | Fax: (810) 229-8947 Helpline: 1-800-444-6443 E-mail: info@biami.org | Website: www.biami.org

THE VOICE OF BRAIN INJURY

Online Directory Update Form

Organization Name:	Date Form Completed

Corporate Address:

Contact Person:	Title:

Phone:	Fax:

Email:	Website :

Facility Information:

Name:

Locations (you may put area served or locations of actual facilities):

Date brain injury program was established:	Parent Organization/system:

Program is: For Profit Non Profit Public Private

Age groups accepted: 0-12 13-22 23-55 56+

Total Capacity:	Capacity dedicated to brain injury:

Number of people with brain injuries served per year:

Program(s) serves people with brain injury resulting from:

Anoxia/Hypoxia Infectious Disease Lightning Strike/Electric Shock Metabolic Disorders

Stroke Traumatic Brain Injury Other

Staff List: Please indicate type of licensed/certified staff (please check up to six boxes)

Alcohol/Drug Counselor

Audiologist

Clinical Dietician

Drivers Education Instructor

Movement Therapist

Neuropsychologist

Neurologist

Occupational Therapist

Orthotist / Prosthetist

Physiatrist

Physical Therapist

Psychologist

Rehabilitation Engineer

Rehabilitation Nurse

Respiratory Therapist

Social Worker

Special Education Teacher

Speech/Language Pathologist

Therapeutic Recreation Specialist

Vocational Rehabilitation Specialist

Physician Consultants as Needed

Other

Service Categories:

Attorney

Case Manager

Cognitive Therapist

Counselor

Expert Witness

Life Care Planner

Neuro-Optometric Rehab

Neuro-Optometrist

Neurologist

Neuropsychiatrist

Neuropsychologist

Neurosurgeon

Occupational

Therapist

Optometrist

Physical Therapist
Psychiatrist

Rehab Nurse

Social Worker

Special Ed. Teacher

Speech/Language Pathologist

Therapeutic Recreation Specialist

Vocational Rehab Counselor

Other

*Please note, anytime you see an “other” field – we are unable to customize it at this time.

Service Specialty – Check all that apply:

al - Alcohol and / or other drug dependency

bh - Behavior Intervention

cc - Concussion Care

co - Coma Management

ct - Clinical Trials

de - Driver Education / Training

hi - Hearing Impairment

hm - Headache Management

ol - Other Language Interpreter

pd - Pediatric

pm	- Pain Management

ps - Psychological Services / Counseling

rd - Respirator Dependent

si - Sign Language

sp - Spanish Interpreter

vi - Visual Impairment

Program Types – Check all that apply:

AA - Air Ambulance

CB - Community Based Program

CM - Case Management

CR - Community Re-entry

DT -	Day Treatment

ED - Education

ES - Medical / Adaptive Equipment Suppliers

HA - Home Health Agencies

IL - Independent Living

LO - Secured Facilities

LT - Long Term Care

MI	- Medical Inpatient Program

OP - Outpatient Medical Rehabilitation

RC - Respite Care

RK - Recreation Program

SC - School

SR - Subacute Rehabilitation

VR - Vocational Rehabilitation

Licenses/Certifications: (list any licenses, certifications or other recognized professional credentials held, the state in which they are valid, license number [if applicable] and expiration date)

License Name	State

License Name	State

License Name	State

Additional states: __ ________________________________

Certification by specialty boards State

Certification number State

Accreditations:

JCAHO

CARF Brain Injury Medical Inpatient Program

CARF Brain Injury Comprehensive Inpatient Program

Category One - Hospital

Category Two - Hospital, Hospital-based Nursing Facility or Skilled Nursing Facility

Category Three - Hospital-based Skilled Nursing Facility or Skilled Nursing Facility

Category Four - Non-hospital based Residential Facilities

Comprehensive Inpatient Program

Home and Community-based Rehabilitation Program

Employment Services (please specify):

Alcohol and Other Drug Program (AOD)

Other

Payment Accepted:

Private Insurance

Medicare

Auto No-Fault

Self-Pay

Government Funding

HMO/PPO

In-state Medicaid

Worker’s Comp

Other

Out-of-state Medicaid

CHAMPUS

Admissions Criteria: (Provide a narrative description [in the space below] of your criteria for admission, limiting your description to 50 characters, including spaces and punctuation).

Program Description: (Provide a narrative description [in the space below] of your program/service, limiting your description to 250 characters, including spaces and punctuation).

Please email your current logo (JPG, GIF or PNG) in no larger than 600 pixels wide to staff@biami.org – please note if logo’s are not in the correct format or size we will not be able to load them into our directory.