SMILE #UWokeUp: TBI SURVIVOR SUPPORT

SMILE #UWokeUp know what a traumatic brain injury entails first hand. Our mission is to give back and help others who are experiencing the aftermath of a traumatizing experience called a TBI.

To apply:

The TBI survivors must have been a patient at Medical Center of the Rockies in Loveland, Colorado, or have been a patient at Poudre Valley Hospital in Fort Collins, Colorado. The TBI survivor who this application is for, has a year from the initial date of their accident to apply for SMILE #UWokeUp TBI survivor support.

 

ARE YOU A: (Please Circle)

Survivor

Family member

Caregiver

Other - Please specify:

DATE OF INJURY: ______________________

IF SOMEONE WERE TO ASK YOU WHY YOU ARE APPLYING FOR SMILEUWOKEUP TBI SURVIVOR SUPPORT. WHAT WOULD YOU SAY AND WHY?

TELL US YOUR STORY?

(PLEASE ADD YOUR STORY ATTACHMENT WITH THE EMAIL WHEN APPLYING OR IF YOU ARE HAND WRITING YOUR STORY. PLEASE SEND IT TO OUR PO BOX: PO BOX 2975, LOVELAND, CO 80539.)

 

ARE THERE ANY DEPENDENTS? ______________________

 

WHAT ARE THE SURVIVORS SHORT-TERM GOALS?

(PLEASE ADD THIS ATTACHMENT TO YOUR APPLICATION.EVERYTHING CAN BE INCLUDED IN ONE DOCUMENT IF YOU NEED MORE SPACE.)

WE SHARE A FEW OF THE FOLLOWING, DO YOU?

COGNITIVE: AMNESIA, INABILITY TO SPEAK OR UNDERSTAND LANGUAGE, MENTAL CONFUSION, DIFFICULTY CONCENTRATING, INABILITY TO RECOGNIZE COMMON THINGS, DIFFICULTY THINKING AND UNDERSTANDING, INABILITY TO CREATE NEW THINGS

BEHAVIORAL: PERSISTENT REPETITION OF WORDS OR ACTIONS, AGGRESSION, IMPULSIVITY, IRRITABILITY, LACK OF RESTRAINT

WHOLE BODY: BALANCE DISORDER, FATIGUE, BLACKOUT, DIZZINESS OR FAINTING

MOOD: ANGER, ANXIETY, LONELINESS, LOUD

EYES: UNEQUAL PUPILS, DILATED PUPIL, RACCOON EYES

GASTROINTESTINAL: NAUSEA OR VOMITING

SPEECH: SLURRED SPEECH OR IMPAIRED VOICE

VISUAL: BLURRED VISION OR SENSITIVITY TO LIGHT

ASO COMMON: PERSISTENT HEADACHE, A TEMPORARY MOMENT OF CLARITY, BLEEDING, BONE FRACTURE, BRUISING DEPRESSION, LOSS OF SMELL, NERVE INJURY, POST-TRAUMATIC SEIZURES, RINGING IN THE EARS, SENSITIVITY TO SOUND, LIGHT, OR STILL MUSCLES

Disclaimer: SMILE #UWokeUp TBI Support is a donation up to $250. This donation will be in the form of a gift card to be used toward household items, groceries and toiletries at our local King Soopers.