Participant Referral Form

The Hamilton Brain Injury Association is a community non-profit organization that offers support to adults in Hamilton living with brain injuries. All programs are free to attend and facilitated by an employee, board member, or volunteer of the organization. Referrals are not required but are always welcomed. Please complete HBIA’s online referral form below (be sure to hit the submit button at the bottom of the page).

Participant Date of Birth *

Participant Email *

Participant Phone *

Preferred Contact Method and Time of Day *

Participant Address *

Program Interest

Date of Brain Injury *

Cause of Injury: *

Referral Source *

Name

Phone

Email

Organization

I certify the above information is correct to the best of my knowledge. By submitting this form I consent to disclose personal information to Hamilton Brain Injury Association (HBIA) and to be contacted by HBIA.

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Contact

Contact Us

Address

B-20 King St. W.
Stoney Creek, ON L8G 1G8

Call Us

+1 289-442-4023

Email Us

info@hbia.ca