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Contact Details Title - None -DrMrMissMrs First Name Surname Address Line 1 Address Line 2 Town/City Postcode/ZIP County/State Country - Select -AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Preferred Course - Select -Mérida, Yucatán - México - 16 January 2019Austin, TX - 23 January 2019Wellington, New Zealand - 30 January 2019London, Wembley - 06 February 2019Bogotá, Colombia - Latinoamérica - 13 February 2019Malmö, Sweden - 14 February 2019Nijmegen, Netherlands (Dutch Course) - 20 February 2019Lima, Perú - Latinoamérica - 20 February 2019Nijmegen, The Netherlands - 20 February 2019Newcastle upon Tyne - 06 March 2019Ciudad de México - México - 06 March 2019Galway, Ireland - 06 March 2019Düsseldorf, Germany (English Course) NRW 03-19 - 06 March 2019Washington, DC - 13 March 2019Singapore - 27 March 2019Greece - Athens - 17 April 2019Seattle, WA - 24 April 2019Istanbul, Turkey - 01 May 2019Bristol Course - 08 May 2019Bengaluru - 12 June 2019Galway, Ireland - 26 June 2019Harrogate - 26 June 2019Düsseldorf, Germany (English Course) NRW 07-19 - 03 July 2019London, Wembley - 24 July 2019Chicago, IL - 07 August 2019Birmingham - 21 August 2019Toronto, ON - 02 October 2019Cork, Ireland - 16 October 2019Düsseldorf, Germany (English Course) NRW 10-19 - 23 October 2019Bristol Course - 23 October 2019Las Vegas, NV - 13 November 2019Stirling - 13 November 2019Dublin, Ireland - 26 February 2020Galway, Ireland - 24 June 2020 Personal Info Gender MaleFemale Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018 Email Address House Phone Number Mobile/Cell Number Occupation Person to contact in an emergency (Name & Number) Tell us about your sports and hobbies including your level of proficiency How did you hear about the programme? TwitterFacebookGoogleNewspaperTV/Radio interviewWord of MouthOther Your Speech History Stammer Perception MildModerateSevere How do you see your stutter/stammer? How do you see your stutter/stammer? - Mild How do you see your stutter/stammer? - Moderate How do you see your stutter/stammer? - Severe What interference does it have in your social life? What interference does it have in your social life? - Mild What interference does it have in your social life? - Moderate What interference does it have in your social life? - Severe What interference does it have in your career? What interference does it have in your career? - Mild What interference does it have in your career? - Moderate What interference does it have in your career? - Severe What other Speech Therapy have you had in the past? What worked best for you and why? Why do you think the other therapies didn't work for you? Lack of Motivation No or inadequate follow-up suport Lack of personal power from therapist Failure to work hard enough Inadequate guidance Unable to grasp techniques Other Reasons? What do you hope to gain from The McGuire Programme? Your Medical History Have you ever been diagnosed with any of the following? YesNo Major Mental Illness? Major Mental Illness? - Yes Major Mental Illness? - No Dyslexia? Dyslexia? - Yes Dyslexia? - No Drug Addiction? Drug Addiction? - Yes Drug Addiction? - No Learning Disability? Learning Disability? - Yes Learning Disability? - No Alcoholism? Alcoholism? - Yes Alcoholism? - No Autism? Autism? - Yes Autism? - No Aspergers Syndrome? Aspergers Syndrome? - Yes Aspergers Syndrome? - No Do you have any physical disabilities? No Yes Please provide details of your disability Are you currently on any medication? No Yes Please provide details of your medication GDPR Consent* I agree 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. Home page Español Français Nederlands Deutsch
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