Application for TBI Support Group Funds
Individual mutual TBI support groups must answer the following questions in order to meet the application for funding requirements.

This form is to be completed by qualified WA State support group facilitators only. All other submissions will not be considered.

Once you have completed this application please complete and submit the budget form on our website (

Our team is available to help you complete this application and the budget form if you require assistance. You can contact us at 877-719-2378 or email us at

*** If awarded funding for your support group you will also need to sign the Letter Of Agreement, complete a yearly budget and pass a Washington State Background check. ***

(This form has been updated January 2019)

I - About Facilitator
Your name *
First & Last
Your answer
Phone Number *
Your answer
Email *
Your answer
Address *
Street address where you receive mail
Your answer
City & State *
City & State for the street address where you receive mail
Your answer
Zip Code *
Zip Code (postal code) for the address where you receive mail
Your answer
Please describe your knowledge and experience working with individuals with TBI *
Your answer
II - About Your Support Group
What is the name of the support group you facilitate? *
Your answer
What is the purpose of your support group? *
examples: A safe place to share experiences, educate, socialize, make new friends, learn better social skills
Your answer
Do you have a majority of regular participants who attend your group due to something related to TBI? *
Survivors, caregivers, family etc?
Where does your support group meet? *
Address of your Support Group Meeting
Your answer
When does your support group meet? *
example: We meet on the first and third Thursday of each month from 7pm to 9pm.
Your answer
On average how many people attend the group meeting? *
Your answer
Does your group meet in locations where the meeting rooms, restrooms, and parking areas are ADA accessible? *
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This form was created inside of Brain Energy Support Team.