Arkansas Traumatic Brain Injury Provider Resource Assessment

On-line Entry - Services You Provide
(Q21)
Please complete and submit the following information:
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  The following two items will be used to link correctly with submission of
other sections.		  
Organization Name  
Email  
Section B continued  
21 Does your organization fund or provide Rehabilitation Services? No
Yes
  If "Yes," please check which services it provides and the setting that are
applicable.  (Check all that apply)		  
  Service Fund Provide Age
<18		 Age
18+		 In-
patient		 Out-
patient		 Day
treatment		 Community
re-entry		 Residential Skilled
Nursing		 Other
1 Acute medical care
2 Acute Rehabilitation
3 Self Advocacy
Training
4 Assistive Technology
5 Case Management
6 Cognitive Therapy
7 Community Agency/
Referral
8 Crisis Care
9 Discharge Planning
10 Driver Education
  Service Fund Provide Age
<18		 Age
18+		 In-
patient		 Out-
patient		 Day
treatment		 Community
re-entry		 Residential Skilled
Nursing		 Other
11 Education/Special
Education
12 Emergency Medical
Care
13 Family Education
Training/Counseling
14 Independent Living
Skills
15 Neurobehavioral
Treatment
16 Neuropsychology
17 Nursing
18 Occupational Therapy
19 Orthodontics
Prosthetics
20 Physical Therapy
  Service Fund Provide Age
<18		 Age
18+		 In-
patient		 Out-
patient		 Day
treatment		 Community
re-entry		 Residential Skilled
Nursing		 Other
21 Post Acute
Rehabilitation
22 Prevention Programs
23 Pre-Vocational
services
24 Psychiatry
25 Psychology
26 Social Work
27 Speech/Language
Therapy
28 Substance Abuse
Evaluation &
Treatment
29 Swallowing
30 Therapeutic
Recreation
  Service Fund Provide Age
<18		 Age
18+		 In-
patient		 Out-
patient		 Day
treatment		 Community
re-entry		 Residential Skilled
Nursing		 Other
31 Trauma Systems
32 Vocational Services
33 Other
  Please explain any "Other" checks
  

Updated 6/27/08 8:15 pm - glowar@sbcglobal.net