Afasic Case Studies
 

Please give us as much information as possible. All completed forms will be kept on file and may be used after 2011.

Thank you for your help.

 
information about your child
Your child's name
Your child's age
Your child's diagnosis
What type of school your child attends (or attended)
Town/county were you live
tell us your story  

where your story can be used  
I would like our story to be used (please tick all that apply) by Afasic
by The Communication Trust
by The Royal College of Speech and Language Therapists
by any other body Afasic deems appropriate
I am happy for our story to be used (please tick all that apply) in newspapers/magazines
on the internet
on TV
on the radio
I am happy to supply a photograph to accompany any published story yes no
Our family would be happy to be interviewed and/or appear (please tick all that apply) on TV
on the radio
in online videos
by journalists working for newspapers/magazines
We would be happy for our real names to be used yes no
your contact details  
Your name
Your email address
Please confirm your email address
Your daytime phone no