If you would like information about session dates and the cost of tuition for attending HCRI, please contact us online or call us at 540-265-5650.

  • Individuals are scheduled for therapy in the order in which their applications are received. There is no charge for submitting an application for treatment in the Hollins Fluency System™

  • The therapy program is conducted 17 times per year.
  • PLEASE NOTE: We encourage school-age children to participate in therapy during the academic year. Most children are not enthusiastic about attending therapy during the summer months. Typically, school-age children accomplish more in therapy when they attend therapy during the academic year.
  • Feel free to request an application to attend the HCRI therapy program by phone or mail. You may also apply by filling in the online application form below in its entirety:

This is an application for participation in HCRI's therapy program.
Please do not fill this out unless you wish to attend HCRI:



First Name

Middle Name

Last Name

Mailing Address:

City:

State:

Zip Code:

Home Phone Number:

Work Phone Number:

E-Mail Address:*

Date of Birth:

Sex:

Native Language:

Occupation:

Employer:

Highest Grade Completed:





Please list all family members, living or deceased, who stuttered. State their relationship to you (brother, uncle, sister, etc.), which side of the family they represent (maternal or paternal) and their stuttering severity(mild, moderate or severe). NOTE: IT IS EXTREMELY IMPORTANT TO COMPLETE THIS SECTION:

Family Member

Living/Deceased

Severity

 

Family Member

Paternal/Maternal

Living/Deceased

Severity

 

General Health

Handedness

Hearing Problems

History of Chronic Ear Infections



At what age did you begin to stutter?



What is your estimate of the present severity of your stuttering?




Is your present level of stuttering your usual severity level?





Please check all of the various types of stuttering therapy that you have received:

Acceptance

Air Flow

Articulation

Counseling or Psychology

Delayed Auditory Feedback

Desensitization

Hypnosis

Metronome

Psychiatric Treatment

Relaxation

Slowed Speech


So that we may better accommodate any special needs that you might have, please indicate any of these conditions that are applicable to you. (please check all that apply):

Additional Speech Problem

Additional Behavioral Problem

Cerebral Palsy

Dyslexia

Learning Disability

Mental Retardation

Required to take medicine

Substance Abuse

Operations in head, neck or chest regions

Other (describe below)

 
Please explain any special condition which influences your daily functioning.

 



If there are any other questions, comments or information that you wish to call to our attention please enter that information below:

 

* required field