HansonHouse TBI Clubhouse in Berea Ohio.

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Membership Form
Contact Information
First Name
Last Name
Middle Initial
Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Pager
Fax
Caregiver Relationship
Health Care
Provider Type
Social Worker Agency
Member TBI Information
 
Date of Injury
(00/00/00)
Cause of Injury
Coma ?
Yes No
Marital Status:
 Married Single
  Divorced Separated
  Widowed
Treatment and Rehabitlitation
Inpatient:
Length of Stay
(00/00/00)
Dates of Stay
(00/00/00)
to
Facility
Outpatient:
Length of Stay
Dates of Stay
 to
Facility
Current Doctor
or Medical Facility
Current Employment
 Volunteer Sheltered Paid
Employer:
Post Rehab Work
 Yes No
Supervisor Name
Supervisor Phone
Transportation Needed:
 Yes No
Attendent Needed?
 Yes No
Program Information

What type of program are you interested in?
  Social       Recreation      Day
Do you have transportion?
Yes No
What times are best for you?
  Day           Evenings      Both
What activites woul you like to do? (Check all that apply)
Art activites Resume writing class
Basketball 12 Step Programs
Coffee house socials Using computers
Card Games Making/Fixing things
Indoor Gardening Walking, hiking
Outdoor Gardening MetroParks
Indians Games Watching Movies
Board Games Dining Out
Comic Books Fishing
Reading Clubs Helping Others
Cooking Classes Parties
Collecting Chess/Checkers
Learning new things Picnics
Museum Visits Golf
Quilt making / Sewing Volleyball
Swimming Live music
Woodworking Bowling
Other? Please list: