Contact the UT Aphasia Research and Treatment Lab

Please complete this form if you are interested in being a participant in our ongoing aphasia treatment research. Please answer ALL questions. If you are filling this form out for another individual, please answer the questions below accordingly. *Please note: this form is not intended for those who are interested in volunteering as a research assistant in our lab.

Participant Name*

First and last name of person who would be considered for the study

Who is filling out this form?

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Why are you contacting us?*

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Tell us more about why you're contacting us

(optional)

Are you reaching out about a specific research study? If so, which?

What is your diagnosis to the best of your knowledge?*

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What variant (or type) of primary progressive aphasia (PPA) have you been diagnosed with?

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What are your current communication difficulties?

What is your email address?*

What is your phone number?*

Where do you live?*

Have you spoken more than one language at some point in your life?

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Do you currently use more than one language?

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Which languages do you currently use?

Are you willing to get a MRI for our research?

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Do you have any metal or other implants in your body?

For example, surgical implants or screws. If yes, please explain.

Do you have a history of any of the following?

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Explain

Is there someone in your life who could be actively involved as your study partner? Who is this person?

A study partner would actively be involved in treatment research. This may involve attending assessment and treatment sessions and/or assisting with study-related technology set up on Zoom.

Do you have access to a computer or tablet with a video camera and internet access?

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Do you have any additional questions, comments, or concerns?

Send me a copy of my responses

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