Please complete all required fields marked with an asterisk (*). Your responses help us understand your professional background and how we can best support you as a Healthcare Partner. Section 1 – Contact Information Full Name * Email Address * Phone Number * Company / Organization Website City / State * Section 2 – Professional Background Professional Role * —Please choose an option—Physical TherapistOccupational TherapistPTACOTANurse / RNNurse PractitionerCare ManagerSocial WorkerHome Health ProfessionalAssisted Living AdministratorHome Care AgencyAging-in-Place SpecialistGeneral ContractorMedical Equipment ProviderOther Are you currently actively practicing or working in this field?* YesNoPart-time / Limited Resume (Optional) Please upload your resume if you would like us to review your experience and background. Section 3 – People You Serve What type of individuals do you primarily work with? * SeniorsIndividuals at high risk of fallsIndividuals with Parkinson's DiseaseIndividuals with mobility challengesIndividuals recovering from surgeryIndividuals with balance disordersIndividuals with vision impairmentsVeteransAssisted living residentsCaregivers / familiesOther Approximately how many patients, clients, residents, or families do you work with each week? * —Please choose an option—0–56–1011–2526–5050+ Of the individuals you work with, approximately how many do you believe could benefit from this system right now? * —Please choose an option—0–55–1010–2525+ Do you regularly work with individuals who are afraid of falling, have already experienced a fall, or struggle to move safely through their homes? * YesNoOccasionally Section 4 – Current Fall Prevention Recommendations Are you currently recommending any fall-prevention products or services to your patients or clients? * YesNo If yes, please describe Section 5 – Program Interest Why are you interested in becoming a Healthcare Partner? * Have you watched the Healthcare Partner overview video? * YesNot yet, but I understand I should watch it before the introductory call Are you interested in learning more about the Demonstration Program? * YesMaybe / I would like more informationNo Section 6 – How Did You Hear About Us? How did you hear about the Healthcare Partner Program? * —Please choose an option—TikTokYouTubeFacebookLinkedInZipRecruiterGoogle SearchReferral / FriendConference / EventHealthcare OrganizationExisting Healthcare PartnerOther If referred, who referred you? Section 7 – Final Question Is there anything else you would like us to know?
