Brain Injury Identity Card application form

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Please use this form to apply for a Brain Injury Identity Card. You can save your progress by clicking on the save link at the top or bottom of each page on the form. You will need to provide an email address and set a password to return to your application.

Note that your application has not been received until you click the 'Submit' button on the final page of the form.

If you have any questions or need assistance, please contact us on justiceproject@headway.org.uk.

Details of the card holder

Please enter details of the person with a brain injury below. If you're applying on behalf of someone else, you'll have the opportunity to enter your details on the next page.
Card holder details

Type the date as dd/mm/yyyy
Photograph

A photograph is required in order to produce your Identity Card.

Please attach a passport style photograph of yourself to this application.

Please ensure:
  • The photo is in colour
  • The photo is clear and in focus
  • The photo is without any creases, marks or tears
  • You are facing forward and looking straight at the camera
  • You are in front of a plain background
  • Sunglasses are not worn (prescription glasses are permitted)
  • You do not have a head covering (unless it’s for religious or medical reasons)
Would you like to receive updates from Headway?

Applying on behalf of someone else - your details

If you are completing this form on behalf of someone else, please enter your contact details here. 
Your details

Would you like to receive updates from Headway?

Evidence of brain injury

In order to provide you with the Headway Brain Injury Identity Card, we require confirmation of your brain injury from your local Headway group or branch, or a clinical professional.

There are two ways to do this.

1 - Upload your evidence

You can upload your evidence via this form. This is the quickest option as it will allow us to start processing your application straight away.

Evidence must include:
  • Your full name
  • Date of birth
  • Medical diagnosis
  • Medical professional’s signature
  • Letter head to show where the document was produced (e.g. from the NHS or a private hospital).
Please note we are unable to accept documents which do not show all of the above information.

2 - Allow Headway to make contact on your behalf

If you are unable to upload this information and would like us to help you attain verification of your brain injury, you can provide us with the contact details of your local Headway group or branch, GP, or the hospital where you were treated.

If you would like us to obtain confirmation by telephone, please tell your nominated professional to expect a call from a Headway representative and supply the phone number below.

A medical professional may need your written consent before they can speak to us. It will greatly speed up the process if you download, complete and return this consent form via email (send a photo or scan of the form) or post (postal address on the form). If you are unable to print the consent form, please get in contact with us and we will gladly post one to you. Please continue with the online application, and we'll start processing it as soon as the consent form is received.

If you would like to continue, please note that in providing us with these details, you are giving your consent for us to make contact with your nominated medical professional or Headway group/branch to seek verification of your brain injury.

About your brain injury

About your brain injury

If you're not sure, just enter an estimated date


Your Brain Injury Identity Card


Your Brain Injury Identity Card will show four statements on the front, which explain how your brain injury affects you. This is shown in the image below. 
Image of the Headway Brain Injury Identity Card, showing four statements on the front

Thinking about how your brain injury affects you on a day-to-day basis, please select exactly four statements from the options below.

Due to space limitations we cannot list more or less than four items on the card, so think about the statements that will be most useful in seeking support. 





Complete your application

Can you help us to understand the impact of brain injury?

Headway would like to learn more about your brain injury and how it affects you, to help us plan, develop and campaign for better services on your behalf.

Please click the 'submit' button below to send your form to us.

This may take a short while as we upload your application to our system, so please don't navigate away from this page until you see the confirmation screen.

You will not be able to return to your application after it has been submitted. 
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