Request to Attend Sessions September 28 & October 51:30 – 2:30PM Full Name * Town/City * Postal Code * Your Email * Telephone * Relationship to the person with aphasia * ---Spouse/PartnerChildSiblingParentOther Cause of aphasia * ---StrokeHead InjuryBrain TumorInfectionOther When did the event causing aphasia take place? * ---Within the last 6 monthsLast 6 months - 2 yearsMore than 2 years ago This is a 2-part workshop. Are you available to attend both sessions September 28 & October 5? YesNo How did you hear about the workshop? * ---Aphasia Centre (Please Specify)Health Care ProviderFriendFamily MemberSocial MediaWebsiteEmail Mailing ListOther Is your family member with aphasia connected with an aphasia centre? YesNo IF yes, which one?