Montana Stroke Survivor Connections

Online Enrollment Form

If you are a stroke survivor or caregiver who would like to enroll in our Montana Stroke Survivor Connections program, please fill out the form below. If you experience issues filling out the form, please give us a call at 800-241-6442.

To learn more about stroke prevention and recovery, visit our stroke page by clicking here.

First Name

Last Name

Primary Phone Number

Secondary Phone Number (Optional)

Street Address

Apartment/Suite (if not applicable, please enter NA)

City

State

Zip Code

Date of Stroke

Language Spoken

Race

Gender

Referred to BIAMT by:

Referee Phone Number:

I give my permission to share the above information with the Brain Injury Alliance of Montana to be enrolled in Montana Stroke Survivor Connections. I am aware that the information that I provide will be provided to BIAMT staff and volunteer peer contacts.

I AGREE

The Brain Injury Help Line DOES NOT REPLACE any medical or rehabilitation services that you may need. It is intended to provide you and your family with information about brain injury and assist in accessing services. You can discontinue this follow-up service at any time. This form grants BIAMT permission to use the categorical data (date of injury, cause of injury, race, and gender) in data collection pertaining to brain injury in Montana.

I AGREE

By using this form you agree with the storage and handling of your data by this website.

I AGREE

Montana Stroke Survivor Connections

Online Enrollment Form

Mission Statement

Contact

Brain Injury Alliance of Montana

3535 West Broadway #6 Missoula, MT 59808

Office: (406) 541-6442

Help Line: (800) 241-6442

Fax: (406) 541-4360

Email: info@biamt.org

Links