Please fill out the following form and click the "Send" button at the bottom when you are done.
Name:
Email:
Who is the potential PEAT user?
Myself My parent My child My sibling My friend My Client or Patient Other
Treatment Goals:
Will you or a caregiver be involved in the treatment?
Yes, I will be involved Yes, someone besides me will be involved No caregiver is available
Is the person currently receiving rehabilitation services?
No Yes, services are provided by: Speech Language Pathologist Occupational Therapist Psychologist MD Nurse Caregiver Other:
Speech Language Pathologist Occupational Therapist Psychologist MD Nurse Caregiver Other:
Which cognitive impairments do you want help with?
Awareness of current time Awareness of elapsed time Breaking large tasks into smaller steps Choice making Error recovery Flexibility Intiation Insight about effects of actions Memory Perseveration (inertia) Staying on task Planning, scheduling and sequencing Sustained Attention Other:
What cognitive aids does the person currently use?
Paper Calendar Paper Memory Book Cellphone Electronic Calendar (PDA): Electronic Cueing: Human assistants: Other:
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: