First and last name of person receiving services (i.e., the client) *

First Name

Last Name

Client's date of birth

MM

DD

YYYY

Phone number *

The best number to reach you at!

(###)

###

####

How would like us to contact you? *

Please select all that apply.

Phone

Email

Text

Other - please specify below

What services would be of interest? Or which would you like to learn more about? *

Please select all that apply.

Private speech and language therapy

Group therapy

Intensive Aphasia Program

Counselling

Training in aphasia and supportive conversation

Other - please specify below

What type of therapy are you looking for?

In-person therapy

Virtual/Online therapy

Open to either option

What is the reason driving you to connect and work with us?

"The client would like to.." (please select all that apply)

Improve their social interactions

Improve their communication skills (speaking, reading, writing, understanding, etc.)

Address mental health concerns

Decrease or help manage challenging behaviours

Maintain daily living skills

Return to work

Other - please specify below