IPV&BI Referral Form - Cridge Centre

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 that are regular and ongoing (not short-term).

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)

First Last

DOB(Required)

Age(Required)

Preferred Pronouns(Required)

What ethnicity would describe you:

Are you a parent?

Yes

Are your children in your care?

Yes

N/A

If yes, how many children do you have?

How old are your children?

Please use commas between ages if you have multiple children.

If anyone else lives in your home, please identify who:

Address(Required)

Street Address Address Line 2 City State / Province / Region

Primary Phone(Required)

May we leave a message?(Required)

Yes

Email(Required)

May we email you?(Required)

Yes

Are you receiving support from any Intimate Partner Violence programs in Victoria? Check all that apply.

Victoria Women’s Transition House

Victim Services

Annie’s Place

The Cridge Women’s Transition House

Bridges for Women

The Cridge Dovetail Program

Rosalie’s Village

Other

If 'other', please specify(Required)

If you have an IPV support worker, please enter their contact information below

Name

First Last

Phone

Fax

Organization

Would you like to be connected to a women’s program or an IPV outreach worker?(Required)

yes

Are you involved with any other programs?(Required)

yes

If yes, which organization/programs?(Required)

Please rate your level of comfort completing the following tasks:

Housework

low

medium

high

Grocery Shopping

low

medium

high

Preparing meals

low

medium

high

Laundry

low

medium

high

Reading

low

medium

high

Time management

low

medium

high

Money Management

low

medium

high

Taking Medication

low

medium

high

Using the phone

low

medium

high

Remembering Appointments

low

medium

high

Initiating Tasks

low

medium

high

Writing

low

medium

high

Using the computer

low

medium

high

Completing Paperwork

low

medium

high

Please identify any specific areas that are challenging:

Isolation

yes

Overstimulation

yes

Regulating your emotions

yes

Memory

yes

Concentration

yes

Maintaining Routine

yes

Chronic pain

yes

Organization

yes

Getting distracted easily

yes

Fatigue

yes

Decision Making

yes

Substance misuse

yes

Relationships

yes

Staying focused

yes

Problem Solving

yes

Speaking or being understood

yes

**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.

Date

IPV & BI Intake Application

Please rate your level of comfort completing the following tasks:

Please identify any specific areas that are challenging:

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