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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 -Córdoba, Argentina - Latinoamérica - 03 April 2019Santiago, Chile - Latinoamérica - 10 April 2019Sydney, NSW, Australia - 10 April 2019Greece - Athens - 17 April 2019Seattle, WA - 24 April 2019Dubai, UAE - 24 April 2019Torreón, Coahuila - México - 24 April 2019Istanbul, Turkey - 01 May 2019Bristol Course - 08 May 2019Aarhus, Denmark - 16 May 2019New York City, NY - 12 June 2019Lima, Perú - Latinoamérica - 12 June 2019Bengaluru, India - 19 June 2019Bogotá, Colombia - Latinoamérica - 19 June 2019Galway, Ireland - 26 June 2019Harrogate - 26 June 2019Düsseldorf, Germany (Eng) - 03 July 2019Dubai, UAE - 17 July 2019London, Wembley - 24 July 2019Gold Coast, QLD, Australia - 24 July 2019The Hague, The Netherlands (NL) - 24 July 2019Chicago, IL - 07 August 2019Birmingham - 21 August 2019Toronto, ON - 02 October 2019Cork, Ireland - 16 October 2019Melbourne, Victoria, Australia - 23 October 2019Düsseldorf, Germany (Eng) - 23 October 2019Bristol Course - 23 October 2019Stirling (please note revised dates) - 06 November 2019Las Vegas, NV - 13 November 2019Dubai, UAE - 04 December 2019New Delhi, India - 11 December 2019Perth, Western Australia, Australia - 05 February 2020Dublin, Ireland - 26 February 2020Wellington, New Zealand - 01 April 2020Galway, Ireland - 24 June 2020Singapore - 09 September 2020 Personal Info Gender MaleFemale Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 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. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Español Français Nederlands Deutsch
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