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

Have you received community/outpatient 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

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

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

Yes

No