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FREE ONLINE SPEECH THERAPY
Please fill out the form if you have aphasia, or are filling this out on behalf of someone with aphasia.
Name of person with aphasia
Name of person filling out the form - if different from above.
Name of a family member or carer who we can contact
Best contact email
Please enter an email address
Please enter a valid email address
Best contact number
What date was aphasia patient discharged from hospital? If they are still in hospital please say when you expect them to be discharged.
Which area does the aphasia patient live in?
What does the aphasia patient find hardest to do?
What is the aphasia patient a bit more capable of doing?
Has the aphasia patient had speech therapy before?
-- Please Select --
If YES, please give us more details - Where was this? How many sessions did they have? Why did it stop?
Is there anything else you would like us to know?