CI Therapy Packet

Welcome to the UAB Taub Therapy Clinic.

If you or a loved one is interested in receiving treatment at the UAB Taub Therapy Clinic, we ask that you fill out the information below so that we may send you a patient application packet and better answer any questions you may have regarding treatment in our clinic.
What is your full name?*
First Last
What is the name of your caregiver or companion?
First Last
Patient Age:
What is your email address?*
What is your full mailing address, including street, city, state, ZIP code, and country (if applicable)?*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What is your telephone number?*
What diagnosis do you or a loved one have?
- Stroke
- Traumatic Brain Injury (TBI)
- Multiple Sclerosis
- Other
If Other, please specify
When did this condition begin for you or your loved one (onset date of this diagnosis)?
Please indicate your interest in the following programs provided by the UAB Taub Therapy Clinic (check all that apply):
- Arm and Hand CI Therapy Program
- Leg and Walking CI Therapy Program
- Speech/Language CI Therapy Program
How did you hear about the UAB Taub Therapy Clinic? (check all that apply)
- My physician
- My therapist
- Book or publication
- Online search
- Web search
- Friend or family member
- Other
How would you prefer to receive our patient application packet?*
- Email
- Standard mail