The HCRI Scholarship Program for stuttering treatment

The HCRI Application Process

Please Note: HCRI therapy is only offered on-site at our facilities in Roanoke, Virginia USA for ages 11 and up. If you are not able to attend treatment at HCRI, or are under the age of 11 years, please CLICK HERE for information about how you can obtain information about other stuttering treatments.

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

GENERAL INFORMATION:

First Name

Middle Name

Last Name

Mailing Address:		Date of Birth:
City:		Sex:
State:		Native Language:
Zip Code:		Occupation:
Home Phone Number:		Employer:
Work Phone Number:		Highest Grade Completed:
E-Mail Address:*

FAMILY HISTORY OF STUTTERING:
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: This section must be completed.

Family Member	Living/Deceased	Severity

OTHER FAMILY MEMBERS:

Family Member	Paternal/Maternal	Living/Deceased	Severity

YOUR HEALTH:

General Health
Handedness
Hearing Problems
History of Chronic Ear Infections

SPECIAL NEEDS:
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):

		If checked, please explain:
	Additional Speech Problem
	Additional Behavioral Problem
	Cerebral Palsy
	Dyslexia
	Learning Disability
	Mental Retardation
	Required to take medicine

Please describe in the box below any other special condition
that influences your daily functioning.

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