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Ambassador Report On Meeting Newly Injured
Ambassador Information
Ambassador Name (first & last)
*
Patient Information
First Name
*
Last Name
*
Email
*
Phone
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Disability Type
*
Disability Type*
Paraplegia
Quadriplegia
Spinal Cord Injury
Spinal Cord Disorder (TM/GB/Polio)
Spina Bifida
Stroke
Amputee
Cerebral Palsy
Multiple Sclerosis
Muscular Dystrophy
TBI
Other
Injury Level / Description
Date of Injury/Diagnosis
Month
Day
Year
Cause of Injury
*
Cause of Injury*
Vehicular
Fall
Violence
Sports/Recreation Activities
Medical/Surgical
Disease/Disorder
Cancer
Congenital
Other
Hospital / Rehabilitation center
*
Northridge
Casa Colina
Rancho
Cal Rehab
Ballard
St. Jude
Sharp
Scripps
Long Beach Memorial
Long Beach VA
Other
If Rehab not listed above: Where?
Veteran
*
Veteran*
Yes
No
Gender
*
Gender*
Male
Female
I Choose Not To Disclose
Race / Ethnicity
*
White
African American
Native American/Alaskan Native
Hispanic/Latino
Asian
Pacific Islander/Native Hawaiian
Multiple Races
Other
Your Current Needs (check all that apply)
Information
Equipment/Services
Encouragement
Care Needs
Transition Home
Rehab
Recipient's most critical needs:
Home Modification
Equipment / Services
Care Giver
Support Network (Family absent)
Other
Their story
*
Hidden: Has a Disability?
Hidden: Has a Disability?
Yes
Hidden: Care Recipient Care Pack Received
*
Hidden: Care Recipient Care Pack Received*
Yes
Hidden
Hidden: Form Date
MM slash DD slash YYYY