We Want to Hear From You

Name *

First Name

Last Name

Tell us about you *

I have neurological condition.

I am a family member, friend or caregiver.

I am a health care provider.

Other

Is this a new diagnosis/condition (less then 1 year)

Yes

No

Have you received community/out patient rehabilitation *

Yes I attended a publicly funded program at an AHS site (Glenrose, Choice, CRIS, STEP forward etc.)

Yes I went to a private clinic and paid

No I was not eligible for an AHS program

No I declined services offered

Not applicable

Health Professionals accessed in the community (check all that apply) *

Neurologist

Physiatrist

Occupational Therapist

Physical Therapist

Psychologist

Social Work

Speech Language Pathologist

Acupuncture

Massage Therapy

Personal Trainer/Kinesiologist

Other

Not applicable

Do you feel you would benefit from more rehabilitation or medical guidance? *

Yes

No

Not sure/Maybe

Could you afford to pay privately?

Yes

Yes but I feel health care should be free

No

Do you have any private insurance to cover the cost of therapy?

Yes

Yes but limited

No