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  • Step Ahead Plus Referral Form

    *Items marked are required details
    To be eligible for referral to the Step Ahead Plus service, the person being referred must meet the above criteria. Please tick all appropriate boxes. If you do not meet all of the above criteria, the person may not be suitable for the service. Please contact the service to discuss the referral before proceeding. Please Note: The Service is not suitable for people with degenerative conditions, with progressive organic disorders or with Alcohol Related Brain Injury. If you do not meet all of the above criteria, the person may not be suitable for the service. Please contact the service to discuss the referral before proceeding. Please Note: The Service is not suitable for people with degenerative conditions, with progressive organic disorders or with Alcohol Related Brain Injury.

  • Details of the acquired brain injury

    Please provide any recent medical or therapy reports that are relevant to this referral.

  • Diagnosis of Brain Injury

    Please select the appropriate type of brain injury box and fill out.
  • Please give all details about your traumatic brain injury. E.g. Was it a road traffic accident, Fall, etc..
  • Please give all details about the non-traumatic brain injury and whether it was a vascular accident, infection, or cerebral anoxia/Hypoxia, etc.
  • Please give all details about your injury
  • Please provide any recent medical or therapy reports that are relevant to this referral.
    Drop files here or
    Accepted file types: doc, docx, pdf, jpg, png.

    • Discretionary Information

      Please feel free to disclose the following information. If you choose NOT to disclose this information you will NOT be excluded from accessing the service
      If Yes, send details of treating physician/current support plan with referral if available
      If Yes, send details of treating physician/current support plan with referral if available

    • Primary Difficulties - Part 1

      Please rate the following domains in terms of impact on functioning.
      3 being the area of most impact
      2 being an area of significant impact
      1 being a minor impact area for this person

    • Primary Difficulties - Part 2

      Tick all areas impacted in each domain.

    • Educational Information

    • Vocational Information

    • Professional Agencies/Services Currently Involved

    • Referral Details - all details must be filled in*

    • Release of Information

      You will be posted a written consent form to sign and return. Please note that we cannot process referrals unless they are accompanied by written informed consent to the release of information and authorisation of discussion between care/service providers.

    Contact us:

    If you have any queries you can contact our Area Office nearest to you:

    Area Office 1

    Dublin and West/Northwest Ireland

    Call: Miriam O’Brien

    Telephone: 01 236 0382

    Email: mobrien@abiireland.ie

    Area Office 2

    Midlands/Southeast Ireland

    Call: Katie O’Dwyer

    Telephone: 052 619 1259

    Email: kodwyer@abiireland.ie

    Area Office 3

    Midwest/South Ireland

    Call: David McCarthy

    Telephone: 066 714 2993

    Email: dmccarthy@abiireland.ie

    Get In Touch With Us

    Acquired Brain Injury Ireland is a business name of Peter Bradley Foundation Limited. Company No. 334659 Reg Charity No. CHY 14289

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