“What is Aphasia?” Booklet Request

Name*

Title/Position*

Profession*
—Please choose an option—Case ManagerCommunication Disorder AssistantCommunication FacilitatorMedical DoctorOccupational TherapistOccupational Therapy AssistantPharmacistPhysiotherapistProgram ManagerRecreational TherapistRegistered DietitianRegistered NurseRegistered Nurse EducatorRegistered Practitional NurseRehabilitation AssistantSocial WorkerSpeech Language PathologistStroke Program SecretaryStroke Support CoordinatorSupportive Housing & Attendant Care ProviderOther

Where do you fit on the continuum of care?*
—Please choose an option—Acute careInpatient RehabOutpatient RehabLong-Term CareCommunity (Aphasia Centre)Community Stroke TeamThe LHIN (home care)Private PracticeStudent (SLP)Student (Other)Other

Mailing Address*

Local Health Integration Network (LHIN) where you work*
—Please choose an option—1 Erie St Clair2 South West3 Waterloo Wellington4 Hamilton Niagara Haldimand Brant5 Central West6 Mississauga Halton7 Toronto Central8 Central9 Central East10 South East11 Champlain12 North Simcoe Muskoka13 North East14 North West

Want to find your LHIN? Use the postal-code look-up tool: http://www.lhins.on.ca/

Phone Number*

Email*

If you are attending an upcoming on-site SCA™ training course at the Aphasia Institute, or if you have attended one in the past, please indicate which date.

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