Therapist Mentoring Program - Mentor Survey

Thank you for your interest in the Cure SMA Therapist Mentoring Program. Please fill out the form below to indicate your interest in becoming a mentor, and a coordinator will be in touch with you shortly. Also, depending on your browser's settings, the alignment of questions and answers may be off slightly.

  Basic Information

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Name:

 

 

   

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City:

 

    

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What's this?

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Question - Required - Degree and/or licensure (check all that apply):
Please make at least 1 selection from the choices below.

 

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(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Check all that apply to your practice:
Please make at least 1 selection from the choices below.

* Setting:
(Select one of the available choices or enter a different value.)



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(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Which of the following motor scale assessment tools are you comfortable demonstrating:
Please make at least 1 selection from the choices below.

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   Please leave this field empty

     

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