Role*
Academic/Research
Family / Friend of Person with Aphasia
Frontline
Healthcare Administration/Management
Other
Volunteer at the Aphasia Institute
Profession*
Case Manager
Communication Disorder Assistant
Communication Facilitator
Medical Doctor
Nurse Practitioner
Occupational Therapist
Other
Personal Support Worker
Pharmacist
Physiotherapist
Program Manager
Recreational Therapist
Registered Dietitian
Registered Nurse
Registered Nurse Educator
Registered Practitional Nurse
Rehabilitation Assistant
Rehabilitation Support Worker
Social Worker
Speech Language Pathologist
Stroke Navigator
Stroke Support Coordinator
Student
Volunteer
If your specific job title is not mentioned in the profession list above, please enter it here. If you are a student, please choose ‘student’ in the list above and enter your field here.
Where do you practice?*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Other country
Prince Edward Island
Quebec
Saskatchewan
United States of America
Yukon
If other country, please mention which country?
Where do you fit on the Continuum of Care? *
Acute Care
Community
Long Term Care
Other
Private Practice
Rehab
Organization*
Phone Number*
Experience working with people with aphasia (# of years) *
1 to 5 years
5 to 10 years
< 1 year
> 10 years
Do you have any accessibility or accommodation requests? Please detail them below (e.g., needing more breaks off camera, etc.)*
I understand that satisfactory completion of this course will require attending the course in full and submitting a course evaluation which includes self-assessment and intent to change*
No
Yes. I understand and agree
If you would like to receive emails from the Aphasia Institute, please confirm your permission for us to contact you for the following (please select one):*
No. I do not want to receive further communication
Yes, I would like to receive all emails (including education, general updates from the aphasia institute, including events)
Yes. I would like to receive emails regarding educational opportunities only