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APPLICATION FORM TO ATTEND AN UPCOMING COURSE.

Contact Details
Personal Info
Your Speech History
MildModerateSevere
How do you see your stutter/stammer?
What interference does it have in your social life?
What interference does it have in your career?
Your Medical History
YesNo
Major Mental Illness?
Dyslexia?
Drug Addiction?
Learning Disability?
Alcoholism?
Autism?
Aspergers Syndrome?
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