Registration – Rehab Professionals

Applicant's Name

Applicant's Email Address

Applicant's Phone Number

Applicant's Home Address

Access Calgary # (if applicable)

Primary Contact Name:

Relationship to Applicant

Primary Contact's Phone Number

Primary Contact's Email Address

Who should our intake coordinator contact? Who should our intake coordinator contact? Applicant Primary Contact

Form Completed by - Name:

Form Completed by - Phone Number:

Form Completed by - Email Address:

Relationship to Applicant: Relationship to Applicant: Family Physician Physician Assistant SLP Nurse Other

Please specify "other:

How did you find out about the Calgary Aphasia Centre (CAC)? How did you find out about the Calgary Aphasia Centre (CAC)? Physician Physician Assistant SLP Nurse CAC Website Stroke Recovery Association of Calgary Health Fair Other

Please specify "other:

When did a speech-language pathologist last see the applicant? Date last seen:

SLP name:

SLP contact information:

Which CAC program(s) is the applicant interested in? Which CAC program(s) is the applicant interested in? Conversation Group Book Club

Does the applicant currently have access to and/or ability to use an internet-enabled computer, tablet device, or smartphone? Does the applicant currently have access to and/or ability to use an internet-enabled computer, tablet device, or smartphone? Yes No

Is the applicant interested in attending CAC programs that are hosted online (e.g., Zoom videoconference)? Is the applicant interested in attending CAC programs that are hosted online (e.g., Zoom videoconference)? Yes No

Communication Diagnosis

Please provide a brief description of the applicant’s receptive and expressive communication abilities:

Please describe any strategies used by the applicant or his/her conversation partners to facilitate their comprehension or expression:

Social and leisure interests:

Glasses Glasses Yes No

Hearing Aids: Hearing Aids: Yes No