Application form to join as a member of the programme.

Have you spoken with one of our regional representatives? If you have then this is the next step to joining the programme.

Fill in the application form and select your course location. Your regional director will get back to you to process your application further.

If you haven’t spoken to a regional representative yet please fill in the short contact form available here.

Your First Name *
Your Last Name *
Your Address Line 1 *
Your Address Line 2
County/State *
Town/City *
Postcode/ZIP *
Country *
Preferred Course Location *

Section Two
Personal details
Which of the following accurately describe(s) you?
Choose as many as you like.
Your Date of Birth (MM/DD/YYYY) *
Please use the following format: MM/DD/YYYY (eg. 05/23/2001)
Please confirm your age
Your Email Address *
Mobile/Cell Number *
Occupation *
If you are in college, school etc. please state 'Student'
Name of person to contact in an emergency *
Phone number to contact in an emergency *
Tell us your sports & hobbies *
What do you like to do in your spare time or competitively? Include level of proficiency out of 10 (10 is HIGH!)
How did you hear about the programme? *

Section Three
Your Speech History

Your Perception of your stutter/stammer?

How do you see your stutter? *
Interference in your social life? *
Interference in your career? *
What other Speech Therapies have you had in the past? *
What worked best for you in therapy and explain why it worked?
Why do you think the other therapies didn't work for you? *

Section Four
Your History

Your Medical History

Have you ever been diagnosed with any of the following?
Major Mental Illness? *
Drug Addiction? *
Learning Disability? *
Alcoholism? *
Autism? *
Aspergers Syndrome? *
Do you have any physical disabilities? *
Please state physical disabilities below *
Are you currently on any medication? *
Please provide details of your medication *

What do you hope to gain from The McGuire Programme? *

GDPR Consent *
This form collects your name, email and content so that we can keep track of the application to join the McGuire Programme. For more info check our privacy policy where you'll get more info on where, how and why we store your data.