As part of your rehabilitation, we offer follow-up services through the Minnesota Brain Injury Alliance/Minnesota Stroke Association Resource Facilitation Program. This confidential and voluntary telephone follow-up service DOES NOT REPLACE any medical or rehabilitation follow-up care that you may need. It is intended to provide you and your family with information about brain injury or stroke and assistance in accessing services and supports.

Participation begins on the date signed. A Resource Facilitator will contact you by telephone within the time period you choose below. You can also call us at 612-378-2742 or 800-669-6442.

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Contact Information Please fill out the following information so that we may contact you.

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Contact In: Select How Soon You'd Like to be Contacted 6 Weeks 4-6 Weeks 2-4 Weeks 1 Week

I have a: Brain Injury    Stroke

The following information is optional, but the more details we have, the better we can initially help you. Or, you can submit the information now that you have provided.

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Caregiver/Guardian Information If you are a caretaker or a guardian for the person listed above, please fill out the information below.

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Authorization By clicking this box, I give permission for the name listed at the top of this form to be part of the Resource Facilitation Follow-Up Program with the Minnesota Brain Injury Alliance and Minnesota Stroke Association.