Questions about BrainSTEPS CO?

Contact:
Janet Tyler, Ph.D.

Phone:
 (303) 866-2879
Email:
 tyler_j@cde.state.co.us

Contact:
Heather Hotchkiss, MSW

Phone:
 (303) 866-6739
Email:
 Hotchkiss_h@cde.state.co.us

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Refer A Student to BrainSTEPS CO

Fill out the following form to refer a student to the BrainSTEPS CO program. All referrals to BrainSTEPS CO should only be made after receiving parent approval. Fields with a light-yellow background are required. The information you enter will be submitted to the appropriate BrainSTEPS CO team in the student's geographic area. Once your student referral has been electronically sent to the BrainSTEPS team, please allow several days for the team leader to contact the parent and school.

Student:
First Name MI Last Name
DOB (e.g. 01/01/2009) Current Age Gender

Race    
   
Referral Contact Information:
Name Email
Phone Cell
  Primary Parent Contact Information:
Name Email
Phone Cell
Address Address (2)  
 
City State Zip
  School Contact (if you have this information):
Contact person name Title  
 
Phone Email Academic year
 
  Injury Information:
Age at injury Educational placement prior to injury



Date of injury
(ex. 01/01/2009)
Classroom grade prior to injury
 
 
Has this student received BrainSTEPS / Brain Injury Resource Team consultation in the past for a previous injury?

 
Has child had a history of any of the following that have been MEDICALLY DIAGNOSED PRIOR to their brain injury occurring?
Therapy

What has this child experienced SINCE his/her brain injury: (does NOT need to be diagnosed)
Therapy

  School district:  
  County:  
  BrainSTEPS:
Date of referral to BrainSTEPS Team
(ex. 01/01/2009)
Initial contact to BrainSTEPS initiated by







  Medical diagnosis as stated in medical record:
 

  Notes:
  Verify Submission: