Chats Brain Injury To I Domestic Screen

HAS YOUR HEAD BEEN HURT?
When your head, neck, or face gets hurt, the injuries might not be visible or show up right away but can
impact your brain and your life in many ways. Please complete this CHATS form and work with your advocate
to get support after a head injury.
Has anyone ever put their hands around your neck, put something over your
mouth, or done anything else that made you feel choked, strangled, suffocated, YES NO
or like you couldn’t breathe?
Have you ever passed out or lost consciousness from an overdose or drug use, a
medical issue, or something else? YES NO
Have you ever been hit or hurt in the head, neck, or face? YES NO
Have you ever hurt your head, neck, or face in any other way? Like hitting your
head on something, in a fall or accident, while using alcohol or drugs, severe YES NO
shaking, or a car crash?
After you were hurt, did you ever feel dazed, confused, dizzy or in a fog, see stars,
spots, or have trouble seeing clearly, couldn’t remember what happened, or YES NO
blacked out? (Doctors call this altered consciousness.)
Has any of the above happened recently? If yes, how long ago? ________ YES NO
Has any of the above happened more than once? YES NO
Are you currently having trouble with anything below? Circle all that apply:
PHYSICAL EMOTIONS THINKING ACCESS TO
Headaches Worries and fears Remembering things Food
Sleeping problems Panic attacks Multi-tasking Health Care/Insurance
Sensitive to light or noise Flashbacks Paying attention or focusing Employment
Vision problems Sadness Problem solving Housing
Dizziness Depression Getting things started Utilities
Balance problems Hopelessness Figuring out what to do next Transportation
Fatigue Anger or rage Organizing things Childcare
Seizures Irritable Controlling emotions or reactions Phone
Are you having thoughts of suicide? YES NO

Are you struggling with alcohol or drugs? YES NO
Are you having any other health issues you want to share with us? YES NO
Even if you did not go, have you or anyone else (like a friend or family member)
ever thought you should see a doctor or a counselor, go to the emergency room, YES NO
or get help for anything above?
Do you want to see anyone for or need help with anything above? YES NO
RESOURCES FOR HEALING
An advocate can give you a copy of JUST BREATHE and
INVISIBLE INJURIES.
JUST BREATHE has self-care ideas for better sleep, calming

your body, managing anger, and more!
INVISIBLE INJURIES has more information about what

happens when your head has been hurt and coping with
common physical, emotional, and thinking challenges.
DAILY LIFE
We want to make our services work for you. Here are some ways we might be able to help.
We can also come up with other ideas.
PHYSICAL EMOTIONS THINKING
Provide ear plugs and/or sleep masks to Create a CARE plan with an advocate Creating checklists or calendars
help with sleep and use other resources in JUST
BREATHE Shorter and more frequent meetings
Use sunglasses or adjust light as with staff; written summaries shared if
needed for light sensitivity Extra check-ins helpful
For balance and dizziness challenges, Identifying and limiting triggers Creating a routine
assignment to a ground floor room if
possible and help decluttering Help identify supports and coping Making appointments for time of day
strategies that you are most alert and clear
HEAD TRAUMA INFORMATION

Referral to:____________________________________________________________________
On _____________ (date), I: I have a prior history of:

Was choked or strangled Being choked or strangled
Was hit on the head Being hit on the head
Experienced altered consciousness Experiencing altered consciousness
What I noticed immediately after: Approximate Number of Times: _______
________________________________ Most Recent Time (date):_____________
I am most concerned about:_____________________________________________________

CHATS, Version 2; Published January 2024.
This tool was produced by the Ohio Domestic Violence Network under grant 15JOVW-23-GK-00743-DISA, awarded by the Office on Violence Against Women, Office of Justice Programs, U.S. Department of Justice. The
opinions, findings and conclusions or recommendations expressed in this tool are those of the contributors and do not necessarily represent the official policies of the U.S Department of Justice.
VERSION 2 • MAY 2024

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HAS YOUR HEAD BEEN HURT?

Are you having thoughts of suicide? YES NO

JUST BREATHE has self-care ideas for better sleep, calming

INVISIBLE INJURIES has more information about what

HEAD TRAUMA INFORMATION

On _____________ (date), I: I have a prior history of:

I am most concerned about:_____________________________________________________

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