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IPV & BI Intake Application

What is the program, and how will it help?

The IPV-BI program aims to support women in community who have experienced intimate partner violence (IPV) and are living with a brain injury (BI) by bringing both services together.

The purpose is to assist survivors with identifying daily living activities that have become challenging while developing and implementing strategies to address those challenges. Individuals are required to be supported by an Intimate Partner Violence program or consent for a referral to an Intimate Partner Violence Program to participate in Brain Injury Services.

Examples of support include but are not limited to:

  • Support with executive functioning (phone calls, making lists, using a calendar, setting reminders, completing forms)
  • Access and accompaniment to medical or other appointments (note-taking, communication support, follow up reminders)
  • Fatigue management (energy budget, time management, scheduling)
  • Home management (organization, chores schedule, doing ‘with’, building routines).
  • Connecting to other community resources, when needed.
  • What will the services look like?

    1-2 meetings per week with a focus on:

  • Strategies for daily living skills and learning new tools, particularly around self-care, household management, medical or other appointments, phone calls and meetings, organization and memory, and parenting.
  • Exploring meaningful engagement opportunities (work/volunteer).
  • Connecting to other community resources to assist with mental health, addictions, support groups, housing, medical needs, emergency or crisis support.
  • Providing brain injury information, including introduction to coping strategies for lifelong brain injury learning and acceptance and understanding of the impacts and outcomes of brain injury.
  • If you would like additional assistance in completing the referral application:

  • Please call Measha Gallagher at 778-430-0730 or mgallagher@cridge.org to schedule an appointment.
  • If you prefer to fill out this application by hand, download it here

  • Name(Required)
    MM slash DD slash YYYY
    Address(Required)
    May we leave a message?(Required)
    May we email you?(Required)
    Are you receiving support from any Intimate Partner Violence programs in Victoria? Check all that apply.

    If you have an IPV support worker, please enter their contact information below
    Name
    Would you like to be connected to a women’s program or an IPV outreach worker?(Required)
    Are you involved with any other programs?(Required)

    Please rate your level of comfort completing the following tasks:

    Housework
    Grocery Shopping
    Preparing meals
    Laundry
    Reading
    Time management
    Money Management
    Taking Medication
    Using the phone
    Remembering Appointments
    Initiating Tasks
    Writing
    Using the computer
    Completing Paperwork

    Please identify any specific areas that are challenging:

    Isolation
    Overstimulation
    Regulating your emotions
    Memory
    Concentration
    Maintaining Routine
    Chronic pain
    Organization
    Getting distracted easily
    Fatigue
    Decision Making
    Substance misuse
    Relationships
    Staying focused
    Problem Solving
    Speaking or being understood

    **Please note: The Cridge Brain Injury Services does not provide emergency services or housing. This program does not have internal access to emergency shelters or housing offered by The Cridge Centre or other programs. Medical documentation is not required to access IPV-BI services – A brief screening will be completed during formal intake to determine eligibility. Screening is not designed to act as a formal diagnosis.

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    The Cridge Centre for the Family

    1307 Hillside Avenue,
    Victoria, B.C. Canada V8T 0A2
    Tel: 250-384-8058
    Fax: 250-384-5267

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