Step Ahead Plus - Referral Form For Professionals

Referral Guidelines

Acquired Brain Injury is an injury to the brain that has occurred after birth. This can occur as a result of, e.g.: a Fall, Assault, Accident, Infection, Stroke, Tumour, Concussion or a Road Traffic Accident.

Please note our Fast Track programme supports people back to pre-existing work, education, volunteering and training. This is called vocational rehabilitation. Our New Track programme is for those seeking a new education or employment place.

We conduct our service primarily via tele-health (video/phone/email support). Firstly we carry out an initial interview via video call. The person may then be invited for a face-to-face vocational assessment. If deemed suitable, the person may then be offered vocational rehabilitation via tele-health.

The service is not suitable for people with degenerative conditions, with progressive organic disorders or with Alcohol Related Brain Injury. There is a high demand for our service, and we have a system in place to manage our referrals. Some people are offered the service before other people.

There are two reasons for this.

The person is currently in work or education and experiencing challenges.
The person is returning to their job or place of education soon.

If the person does not meet these conditions, they may have to wait longer for a place on Step Ahead Plus.

When completing this form, fill in as much detail as possible so we can process the person's referral. If you need any support with this referral please contact
Katie ODwyer
E: kodwyer@abiireland.ie
052 6191259/ 086 0329413

Once submitted, you will receive a copy of your completed referral via email for your records.

Referral Criteria

To be eligible for referral to the service, the person MUST, at a minimum, meet the following criteria.

Please select:(Required)

Have a primary diagnosis of an Acquired Brain Injury

Medically stable

Referred by any Healthcare Professional or relevant organisation who can confirm an acquired brain injury diagnosis

Willing to engage in a vocational assessment with the aim of returning to work, training or education

Is the person able to access videocall software? (Zoom or Microsoft Teams)

Is the person willing to provide proof of age? (We are funded by the EU and it is part of their requirement that we check everyone is over 16 years through passport, driver’s licence or birth cert)

If you have answered No to any of the above, the person may not be suitable for the service so please contact us to discuss the referral before proceeding.

Referral Documents

You will need the following document to make the referral to Step Ahead Plus: Consent Forms(Required)

Please click the link on the right to download the Consent Forms document. This includes a consent form that the person with an ABI completes. It is mandatory that the person with the ABI completes the consent form and it is uploaded to process the referral.

Drop files here or

Max. file size: 5 MB, Max. files: 5.

Download Consent Form Now

Please upload any relevant reports such as discharge summary, therapy reports, cognitive assessments, rehabilitation plans, risk assessments, mental health support plans, substance use support plans etc.

Drop files here or

Max. file size: 5 MB, Max. files: 5.

This is not mandatory to process your referral but can help us to screen the referral more effectively.

Emergency Contact

We ask for contact details of a person that we can contact in the unlikely event of an emergency. This is called an Emergency Contact. An example of an emergency would be where the person becomes ill during a session with a Step Ahead Plus staff member and we would phone the Emergency Contact to let them know. This is usually a family member, close friend, or trusted neighbour.

The Emergency Contact form is available for download here. If you can complete this form, it will speed up the referral process.

Download Emergency Contact Form Now

Can you complete this form?(Required)

Yes

No

Please click on the link to the right, above, to download the Emergency Contact form document.(Required)

This includes a consent form that the Emergency Contact person completes.

Max. file size: 5 MB.

We will contact the Emergency Contact to gain their consent to keep their details on file. Please provide the following details:

Name of Emergency Contact(Required)

First Last

Phone number of Emergency Contact(Required)

We also require an email address OR a home address so we can contact them.

Email address OR home address of Emergency Contact(Required)

Personal Details

Please fill out the personal details of the person with the ABI being referred

Name(Required)

First Last

Email address of person referred(Required)

Home Phone

Mobile Phone(Required)

Date of Birth(Required)

dd/mm/yyyy

Gender(Required)

Male

Female

Prefer not to say

Address(Required)

Street Address Address Line 2 City County / State / Region Eircode

This field is hidden when viewing the form

Health Service Executive Area:

GP Details

Please fill out the GP details of the person with the ABI being referred

GP Name(Required)

GP Phone(Required)

GP Address(Required)

Street Address Address Line 2 City County / State / Region Eircode

Additional information

Has the person being referred a history of substance use?(Required)

Yes

No

If yes, is the person engaged in or have they completed a Rehabilitation Programme?

Yes

No

Give Details

Please send details of treating physician / current support plan with referral if available

Drop files here or

Max. file size: 10 MB, Max. files: 5.

Has the person being referred a history of mental health challenges?(Required)

Yes

No

Give Details

Please send details of treating physician / current support plan with referral if available

Drop files here or

Max. file size: 10 MB, Max. files: 5.

Please give details of any other risks associated with this referral that the person chooses to disclose

Services Currently Involved

Past therapy services attended (e.g. Occupational Therapy, Physiotherapy, Speech & Language Therapy, Psychology, etc.)

Current therapy or support services (e.g. Occupational Therapy, Physio, Speech & Language Therapy, Psychology, Rehab Assistant, Personal Assistant, HSE service, Case Manager, Day Service etc). Please provide contact details.

Has the person referred been referred to the National Rehabilitation Hospital?(Required)

Yes

No

If the client is currently engaged with your service, please outline current goals.

Referral Details

All details must be filled in.

Name of person completing this form:(Required)

Date of Referral:(Required)

Signature(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Contact phone number:(Required)

Contact email address:(Required)

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Step Ahead Plus - Referral Form For Professionals

STEP AHEAD PLUS - For Professionals Referring Individuals

Referral Guidelines

Referral Criteria

Referral Documents

Emergency Contact

Personal Details

GP Details

Details of Acquired Brain Injury

Primary Difficulties

Additional information

Education Information

Vocational Information

Why would the person like to take part in Step Ahead Plus?

Services Currently Involved

Referral Details

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