Creating a better future through brain injury prevention, research, education, advocacy, and support.

Resource Request Form

To receive information from the Brain Injury Association of Virginia's clearinghouse, indicate the subjects that interest you. (If you don't see what interests you here, call BIAV -- more may be available.)

To conserve resources - we cannot process forms with all subjects marked. Please limit your selection to five (5) topics. Thank you for your understanding.

For a printable version, click here for the request form . Mail the completed form with any payments to:

Brain Injury Association of Virginia
1506 Willow Lawn Dr., Suite 112
Richmond, VA 23230

INFORMATION ON BRAIN INJURY

BIAV PUBLICATIONS AND COMMUNITY RESOURCE LISTS

PLEASE FILL OUT COMPLETELY OR YOUR ORDER CANNOT BE PROCESSED

Name Street Address Address (cont.) City or Province County (if in VA) State Zip Code Daytime phone (in case there is a question about your order)
E-mail Address
May we e-mail you the material requested? (If available in that format?)

To help us choose the most relevant information, please complete the following.

I am:

Please specify type of professional.
When did the brain injury occur (month/year)?
Cause of brain injury or type of brain injury
What is the current age of the survivor?


Please add any information below that can help us select the most appropriate material.

Are you a current member of the Brain Injury Association of Virginia?

As a non-profit organization, the Brain Injury Association of Virginia relies on the generosity of donors to make this information available to everyone who needs it, regardless of their ability to pay. Please consider a donation, if you can, to help cover the cost of printing and postage. All contributions are tax deductible.

Thank You.

 

 

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