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 Other:
What cognitive aids do you use with your clients?
Paper Calendar Paper Memory Book Cellphone Electronic Calendar (PDA): 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 $100 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 clients' cognitive therapy or 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:
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:
If you have a specific client you think may benefit from PEAT, please fill out the following client profile:
Medical Diagnosis Date of Injury Treatment Goals: Goal One Goal Two Goal Three Will a caregiver be involved in the treatment? Yes, full-time caregiver will be involved. Yes, a part-time caregiver will be involved. No caregiver is involved Is the client currently receiving rehabilitation services? No Yes, services are provided by: Speech Language Pathologist Occupational Therapist Psychologist MD Nurse Caregiver Other: Which cognitive impairments does the client need 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 client currently use? Paper Calendar Paper Memory Book Cellphone Electronic Calendar (PDA): Electronic Cueing: Human assistants: Other:
Treatment Goals:
Will a caregiver be involved in the treatment?
Yes, full-time caregiver will be involved. Yes, a part-time caregiver will be involved. No caregiver is involved
Is the client 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 does the client need 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 client currently use?
End of Survey