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Contact Details

Title

First Name

Surname

Address Line 1

Address Line 2

Town/City

Postcode/ZIP

County/State

Country

Preferred Course

Personal Info

Gender

Date of Birth

Month

Day

Year

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?

Your Speech History

Stammer Perception

	Mild	Moderate	Severe
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?

	Yes	No
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?

Yes

Please provide details of your disability

Are you currently on any medication?

Yes

Please provide details of your medication

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