Step Ahead Plus - Referral - Acquired Brain Injury Ireland

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 Collision.

Please note our Fast Track programme supports people back to pre-existing work, third level education 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. You may then be invited for a face-to-face vocational assessment. If deemed suitable, you 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:

You are currently in work or education and experiencing challenges.
You are returning to your job or place of education soon.

If you do not meet these conditions, you 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 your referral. If you need any support with this referral please contact:

Katie O'Dwyer
E: kodwyer@abiireland.ie
T: 052 619 1259 / 086 032 9413

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, you MUST, at a minimum, meet each of the following criteria. Please tick to confirm.

Please select:(Required)

Have a primary diagnosis of an Acquired Brain Injury

Be medically stable

Provide a document confirming you have an acquired brain injury diagnosis e.g. medical report or discharge letter

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

Are you able to access video call software? (Zoom or Microsoft Teams)

Are you 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, you may not be suitable for the service so please contact us to discuss the referral before proceeding.

Where did you hear about Step Ahead Plus?

You will need the following documents to make the referral to Step Ahead Plus:

1) A letter from a medical professional confirming your diagnosis of acquired brain injury e.g. discharge summary or a report.(Required)

Drop files here or

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

This is a mandatory document so we can process your referral.

2) Reports: Please upload any other relevant reports that can help us to understand your current situation e.g. therapy reports, cognitive assessments, rehabilitation plans, mental health or substance use support plans.

Drop files here or

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

This is not mandatory but can help us to understand the symptoms you are experiencing.

Personal Details

Please complete the information below for the person to be referred to Step Ahead Plus.

Name(Required)

First Last

Email(Required)

Contact Phone Number(Required)

Additional Phone Number

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

GP Details

GP Name(Required)

GP Phone(Required)

GP Address(Required)

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

Additional information

Do you have a history of substance use?(Required)

Yes

No

If yes, have you engaged in or 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.

Do you have 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.

Is there anything else you would like to disclose that can help us to understand your current situation?

Services Currently Involved

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

Have you been referred to, or are you being seen by another service? (e.g. ABI Ireland Community Services, Occupational Therapy, Physiotherapy, Speech and Language Therapy, Psychology, Rehabilitation Assistant, Personal Assistant, HSE service (Case Manager, Day Service, etc)? Please provide contact details including name and location of service(s).

If you are currently working with another therapy service, please outline your current goals, for example ‘learning how to use a diary' or 'upper limb therapy’

Have you been referred to the National Rehabilitation Hospital in Dún Laoghaire?(Required)

Yes

No

Do you consent to Step Ahead Plus liaising with the National Rehabilitation Hospital (NRH) to update them on your referral to Step Ahead Plus?(Required)

Yes

No

Referral Details

All details must be filled in.

Are you completing this form on behalf of someone else?(Required)

Yes

No

Name of person completing this form:(Required)

Date of Referral:(Required)

Contact phone number:(Required)

Contact email address:(Required)

Consent Forms

Please read the information below and sign this form if you consent to sharing information with Step Ahead Plus – assessment and rehabilitation service.

• I give my permission to Acquired Brain Injury Ireland (ABI Ireland) to collect information on my clinical, educational, and work history. I understand that they need to collect my information to provide me with their Step Ahead Plus Service.

• I understand that ABI Ireland will keep my information on a secure electronic database and in a paper copy that is kept safe.

• I understand that ABI Ireland will not share my information and assessment report with anyone outside of ABI Ireland without my consent.

• If I want to withdraw my consent, I will contact the Step Ahead Plus administrator Katie O'Dwyer at kodwyer@abiireland.ie or +353 86 032 9413.

• If I withdraw my consent, it will not apply to my information that has already been shared.

• My information, written and electronic, will be held only for use by the Step Ahead Plus service. If I am offered a service, my information will be kept on file. We will hold your information until 2034 in line with our EU funder's policy.

• If I want to withdraw my consent, I will write to ABI Ireland to tell them.

• My information, written and electronic, will be held only for use by the Step Ahead Plus service. If I am offered a service, my information will be kept on file. This is in line with the Data Protection Act 2003.

• ABI Ireland might use my information to help them monitor the demand for the services so they can develop the organisation.

• Data from outcome measurement may be used by ABI Ireland for audit and research purposes but the person served will not be personally identifiable in any publication.

• If I cannot sign this form myself, I can choose someone to sign it for me.

Can you sign this consent form?(Required)

Yes

No

Please tick the relevant box for this statement: "I agree to Acquired Brain Injury Ireland collecting and storing my information for the purposes described above".(Required)

Yes

No

Name(Required)

Date of Birth(Required)

Signature(Required)

Date of signature(Required)

If the person is unable to sign the consent form, this section is to be completed by a person that they nominate to sign it on their behalf.

Name of person to be referred(Required)

Name of nominated person signing on their behalf(Required)

I, the nominated person, have discussed the above information about the provision of consent with the person referred to Step Ahead Plus. I can confirm that he/she wishes to give consent to Acquired Brain Injury Ireland to release his/her background information to relevant organisations/individuals. I can also confirm that he/she understands that he/she can revoke this consent at any time.

Signature(Required)

Date of signature(Required)

Relationship to the Person Referred

(i.e. Next of Kin, Next Friend, Parent or Legal Guardian)

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.

At this time, is the nominated Emergency Contact person able to provide their personal contact details and consent to us storing their information?(Required)

Yes

No

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

We require your consent as Emergency Contact to keep your contact details on file.

• I understand that ABI Ireland will keep my information on a secure electronic database and in a paper copy that is kept safe.

• My information, written and electronic, will be held only for use by the Step Ahead Plus service. This is in line with the Data Protection Act 2003.

• I understand that ABI Ireland will not share my information with anyone outside of ABI Ireland without my consent.

• If I want to withdraw my consent, I will write to ABI Ireland to tell them.

• If I withdraw my consent, it will not apply to my information that has already been shared.

• If I cannot sign this form myself, I can choose someone to sign it for me.

As the nominated Emergency Contact person, please tick the relevant box for this statement: "I agree to Acquired Brain Injury Ireland collecting and storing my information. I give my permission to Step Ahead Plus (as part of Acquired Brain Injury Ireland) to hold my name and contact information which may be used in the event of an emergency relating to the person being referred to Step Ahead Plus.(Required)

Yes

No

Name of Person Referred to Step Ahead Plus(Required)

First Last

Name of Emergency Contact(Required)

First Last

Name of Emergency Contact(Required)

First Last

Emergency contact phone number:(Required)

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

Relationship to Person Referred(Required)

Email address OR home address of Emergency Contact(Required)

Signature of nominated Emergency Contact(Required)

Date(Required)

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Step Ahead Plus - Referral Form

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