Regional contacts

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Online Application

(Please do not use your return/enter key until finished as it will submit your application prematurely.)
Name

 

Home Address:

  
Street
Area:
City/Town:
Postcode:
Country:
Phone:
E-mail:
Date of Birth:
Highest Level of Education:
Marital Status:
Occupation:

Name and telephone number of emergency contact (next of kin):

 

How do you see your stammer:   Mild Moderate Severe
Interference in social life: Mild Moderate Severe
Interference in career: Mild Moderate Severe
Motivation to overcome it: Low Medium High

Physical Disabilities?      Yes       No        If 'Yes' then please tell us more


Have you been diagnosed with any of the following?:

Major mental illness Yes No
Dyslexia Yes No
Drug addiction Yes No
Learning disability Yes No
Alcoholism Yes No

Are you currently on any medication?     Yes       No        
If 'Yes' then please tell us more


Tell us about your sports and hobbies including your level of proficiency:

What other speech or (speech related) psychotherapy have you had?

What worked the best for you and why?

Why do you think the other therapies didn't work for you?

  Lack of motivation
  Failure to work hard enough
  No or inadequate follow-up support
  Inadequate guidance
  Lack of personal power from therapist
  Other reasons
 

What do you hope to gain from our programme? What do you want to do that requires good speaking ability?

How did you hear about the McGuire Programme?

Internet search engine (Google, Yahoo, etc.)?

If yes, which search engine?

Television?

Radio?

Name of television or radio programme:

Newspaper or magazine article?  

Newspaper or magazine advertisement?

Yellow pages?

Speech therapist, psychologist, medical doctor?

Can you be contacted for follow-up success evaluation by an outside agency?   Yes     No   

Looking at the schedules of intensive courses in your region on our website (click here) which one would you like to attend?