LifeSkillsVillage.com
  • Services
    • Neuro Rehab
    • Vocational Rehab
    • Neuropsych Tests
    • Supervised TBI Residential
    • Speech-Language Pathology
    • Individual Outpatient Services
    • Pain Self-Management
    • Telemedicine
    • Social Activities
  • Refer
  • Admissions
    • Guest Day
    • Tour
    • Getting Started
    • Forms
    • FAQ
  • Us
    • Ethics
    • Outcomes
    • Team Profiles
    • Careers
  • Resources
    • Support Groups
    • Glossary of TBI Medical Terms
    • COVID-19 Resources
  • Contact

Forms

Download Intake Paperwork.

intake_packet_2020.4.27.pdf
File Size: 1337 kb
File Type: pdf
Download File

Download Printable Script

new_script.pdf
File Size: 16020 kb
File Type: pdf
Download File

Intake Checklist:

The client’s case manager and legal guardian are required to be present at intake. Please send all requested documents and completed paperwork to Life Skills Village TWO DAYS BEFORE your scheduled appointment:

1.  Client Registration form, including:    
  • Physical address where client currently resides
  • Contact information for all case managers (both internal and external)
2.  List of guardians and caregivers
3.  ER Records
4.  Hospital records
5. List of all treating physicians (primary, neurology, PM&R, psychiatrist, etc.)
6. List of all providers involved in your care (psychologists, behaviorists, vocational, recreational, occupational, speech-language pathologists, physical therapists)
7. Current insurance information
8. State issued identification (to be scanned at appointment)
9. Insurance cards (to be scanned at appointment)
10. Signed prescription from physician or referral from a psychologist
11. Copies of any brain imagining
12. Notes from prescribing physician
13. Signed Assignment of Benefits form
14. Signed HIPAA Authorization and Release forms
15. Current neuropsychological report (completed within the last 12 months)
16. Attorney contact information
17. Transportation contact information
18. If TBI is related to a motor vehicle accident, we will also require a copy of the
  • Police Report
  • EMS Records
Fax all completed forms to Life Skills Village at 248.605.8099.
Please note that failure to have these documents completed and to Life Skills Village within two days of you appointment may result in your intake/assessments being rescheduled.
  • Services
    • Neuro Rehab
    • Vocational Rehab
    • Neuropsych Tests
    • Supervised TBI Residential
    • Speech-Language Pathology
    • Individual Outpatient Services
    • Pain Self-Management
    • Telemedicine
    • Social Activities
  • Refer
  • Admissions
    • Guest Day
    • Tour
    • Getting Started
    • Forms
    • FAQ
  • Us
    • Ethics
    • Outcomes
    • Team Profiles
    • Careers
  • Resources
    • Support Groups
    • Glossary of TBI Medical Terms
    • COVID-19 Resources
  • Contact