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 and/or caregiver.

I am a health care provider.

Other

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

Yes

No

Do you feel you would benefit from more rehabilitation? *

Yes

No

Not sure/Maybe

At this time, could you afford to pay for private services?

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

Do you feel you would benefit from wellness programming? *

Yes

No

Not sure/Maybe

Would you like to be contacted once the center is open? *

Yes

No