Please fill out the following form and click the "Send" button at the bottom when you are done.
Name:
Email:
Occupation or Background
MD Neuropsychologist Occupational Therapist Speech Language Pathologist Nurse Hospital or Medical Center employeee Non-profit employee Assistive Technology Engineer Educator Professional Caregiver Other
Which cognitive disorders do you work with?
Brain Injury Stroke Multiple Sclerosis Brain Tumor Autism Developmental Disorders Attention Deficit Disorder Alzheimer's Diseasee Other
How many people with cognitive disorders do you see each month?
Less than 5 Between 5 and 10 Between 10 and 20 Between 20 and 30 More than 30 Other
How many hours per patient per month?
Which cognitive impairments do you see in your clients?
Awareness of injury Awareness of elapsed time Choice making Error recovery Intiation Insight about effects of actions Memory Perseveration Planning, scheduling and sequencing Sustained Attention Comments:
What cognitive aids do you use with your clients?
Paper Calendar Paper Memory Book Cellphone Electronic Calendar: Electronic Cueing: Human assistants: Other:
What other assistive technology do you use with your clients?
Communication aids: Vision aids: Hearing aids: Other:
What is maximum price of assitive technology you purchase or prescribe for clients?
0, we don't use assistive technology Up to $250 Up to $500 Up to $1,000 Up to $2,500 Up to $5,000 Up to $7,500 Up to $10,000 Up to $15,000 More than $15,000
Who pays for your client's assistive technology?
Personal funds Private Health Insurance Auto Insurance Workers compensation Medicare/Medicaid State Dept. of Rehab. (or Vocational Rehab). VA (Veteran's Affairs) Goodwill Easter Seals Other:
Who pays for your client's cognitive therapy services?
Who performs the therapy services?
Speech Language Pathologist Occupational Therapist Psychologist MD Nurse Caregiver Other:
Do you have a specific client you think may benefit from PEAT?
Not currently. Yes, I have one or more specific clients in mind.
How did you hear about PEAT?
Internet Professional Colleague Friend Conference Magazine Journal Other:
Have you heard about PEAT before today?
No. This is the first time I've heard of PEAT. Yes, but I've never seen a demo. Yes, I've seen it before but never used it. Yes, I've used it in the past but not currently. Yes, I'm a current PEAT user. Please comment about your previous PEAT experience: