Monthly Facilitator Check-In
Hello! I hope you had a great month of meetings and activities.

As part of the contract we have with WA State DSHS facilitators who receive direct support group funding are required to provide monthly updates.

We use these updates to monitor our effectiveness as administrators of the funds, share the many great activities, successes, and challenges of our Washington State brain injury support groups to DSHS.

If you need assistance completing the form please contact us at 877-719-2378 or email Adriana Hashem at

Be sure to click submit at the end of the form.

Thank you for all that you do.

What is the name of your support group? *
If you chose Other please tell us the name of your support group.
Your answer
How did things go at your support group this month? *
If your answer was either "Okay. Some hiccups" or "Sucked! Please Help!" please share a brief description of the challenges you experienced.
Your answer
Approximately how many people attended your activities this month? *
An estimate of the number who attended is fine. Adding together all your events, activities and meetings in one month how many people attended this month? If one person attended multiple activities please count each time they attended.
Your answer
How many members of your group are individuals with brain injury? *
Your answer
How many members of your group are caregivers or family members of an individual with brain injury? *
Your answer
How many members of your group are youth? *
Please note that for this question youth are between the ages of 13 and 25.
Your answer
How many members of your group are Veterans? *
Your answer
Please share with us what your group did month. *
Describe what your group did this month; went to a museum, had a BBQ, hosted a speaker on meditation, etc. Do not include personal information about participants.
Your answer
What did you spend your DSHS Direct Support Group funding on this month? *
Please select all categories that apply.
Were there any significant changes in spending you had not budgeted for? *
An example of a significant change is if you did not budget for meeting space rent and mid-year had to move and began paying rent for a conference room. Please note we may contact you for details
Are you receiving the support and/or guidance you need from BEST?
If you answered "No" to the previous question please share a little more about your answer.
Your answer
Is the training provided relevant and/or helpful to you as a facilitator?
Please list any questions or concerns and how we might help you?
Your answer
Would you, or members of your group, be interested in attending the next Washington State TBI Advisory Council Meeting?, *
The WA TBI Advisory Council meets every other month from 9am to 3pm at the Emerald Queen Conference Center in Fife WA.
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This form was created inside of Brain Energy Support Team.