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What best describes you?*

I am a stroke survivorI am a caregiverI am a healthcare professionalOther
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How long ago did the stroke occur?*

Less than 6 months ago6 or more months ago
Which side was affected by the stroke?*

LeftRightBoth
Stroke survivor date of birth?*

MonthDayYear
Date
Have you ever tried or are you currently participating in any form of Physical or Occupational Therapy for stroke recovery?*
Are you a resident of the United States of America?*

YesNo
What type of insurance do you have?*
Age of Stroke Survivor*
Who is your insurance provider?
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YesNo

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What is Your Name?*

First NameLast Name
City*
State*
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5-Digit Zip Code
Email*
example@example.com
Address

Street Address

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Phone Number*
Please enter a valid phone number.
Is this a Mobile Phone number?*
Are you eligible for veteran benefits?

Yes, I am an eligible veteran.
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