CLF
HelpLine

We’re Here For You

need help with the form?

The CLF HelpLine provides personalized support to those struggling with the outcomes of brain injury, as well as their families. If you or a loved one have suffered a recent concussion, are struggling with lingering symptoms, or are concerned about CTE, we want to hear from you.

Fill out the form below and a dedicated member of the Concussion Legacy Foundation Canada team will be in touch as soon as possible.

Share a Request for Support

Contact Information

Please fill out your information. You will be the main point of contact for this HelpLine request.

First Name

Last Name

Country

Address

City

State/Province

Use abbreviated state name (Ex. New York = NY)

Postal Code/ZIP Code

Phone Number

Confirm Email

Please ensure this email matches the one above.

ValidateEmailfield

What is your preferred method to be contacted?

If you select "Phone Call," please follow instructions to book a call at the link in your confirmation email upon submission. If you do not see an email, please check your junk inbox or check the spelling of your email. Phone appointments are available in the US and Canada.

Patient Information

This section asks about the patient and their history of brain trauma exposure. Complete this section to the best of your ability regarding your knowledge of the patient's history so CLF HelpLine case managers can respond with the best possible resources. Some responses are required to submit the form.

Are you looking for help for yourself or someone else?

The patient is my...

Child, Spouse, Friend, Client, etc.

Patient City

Patient State/Province

Use abbreviated state name (Ex. New York = NY)

Patient Year of Birth (YYYY)

We ask for age because some medical providers have age requirements.

Patient Gender Identity

Patient Race

Patient Military Service

Patient Military Status - Pre or Post 9/11?

If the patient's service ENDED before 9/11/2001, select "Pre 9/11"

Patient Military Branch

Do you feel you or the patient is experiencing a crisis? Please rate the level of crisis from 1-5, with 1 being "not in crisis" and 5 being "in active emergency."

DISCLAIMER: The CLF HelpLine is not a crisis helpline, however we can direct you to crisis-related resources.

Which of the following selections best captures your reason for reaching out?

A recent concussion/mTBIPersistent Post-Concussion Symptoms (PPCS)Suspected Chronic Traumatic Encephalopathy (CTE) symptomsEnrolling in clinical researchOther

If you selected other, what are you looking for help with?

Which of the following options would be most helpful to meet your needs?

Medical provider recommendationsMental health provider recommendationsConnection with peer supportInformation about symptomsInformation about treatmentsInformation about clinical researchCaregiver resourcesOther

If you selected other, what would be most helpful to meet your needs?

Please estimate the patient’s number of concussions (diagnosed or not).

When did the patient’s most recent brain injury occur?

Please estimate the patient’s number of years of exposure to Repeat Head Impact (RHI) from sources such as contact sports, military service, intimate partner or domestic violence, etc.

ie. number of years exposed to RHI

Please select the sources of concussion and/or exposure to Repeat Head Impact (RHI):

SportMilitary ServiceOccupational Hazard (First Responder, Tradesperson, Health Worker, etc.)Fall, Accident, Motor Vehicle AccidentIntimate Partner Violence, Domestic Violence, AbuseAssaultOther

Please select the level(s) at which the patient participated in sports:

YouthHigh SchoolCollege/UniversitySemi-ProPro

Please select the primary sport(s):

Please share the college or university at which the patient sustained head trauma in sports, if known:

Please share the professional team or organization for which the patient played and sustained head trauma, if known:

If you selected "Other" as a source of concussion and/or exposure to RHI, please share the source:

What symptoms is the patient currently experiencing?

Has the patient seen a doctor or medical provider?

What doctor(s) has the patient already seen?

The patient has seen their primary care or family medicine care providerThe patient has seen one specialistThe patient has seen multiple specialists

If the patient has seen one or more specialists, please list them:

Ex. Neurologist, Dr. XYZ

Has the patient received medical or mental health treatments?

What treatment(s) has the patient tried, if known?

If no treatment was tried, why?

Ex. Lack of health insurance

Is there any other relevant information you would like to share with our case managers?

Referral Information

What college or university alumni network do you feel most connected to?

We ask this because some alumni networks offer support and resources. This could be where you attended, graduated, work, or have another connection.

How did you hear about the CLF HelpLine?

If you selected other, how did you hear about us?

Contact Information