Facebook
Twitter
LinkedIn
Google+
Phone  855-236-7032
Leader in Scientifically Based Stuttering Therapy
Effective Stuttering Therapy in 12 Days

Apply To Attend HCRI Stuttering Therapy

If you are ready to take control of your stuttering and attend one of HCRI's 12-day intensive treatment programs, click on the link below to begin the application process.

Once you submit your application form, we will contact you to schedule your therapy session.
 

Here is the process...
  • We will review your information right away and determine your specific therapy needs. 
  • Within a few days, you will hear from us to schedule your therapy, as well as provide information on fees, funding options, travel and lodging, and more. 
  • Financing is available. If this is of interest, just let us know.
HCRI stuttering therapy is held in Roanoke, Virginia and is designed for people ages 11 and up. (If you are interested in therapy for someone under the age of 11, click here.)  We look forward to welcoming you to our Institute!
 

This is an application form for participation in HCRI's therapy program.
* required field

GENERAL INFORMATION:

First Name*   

Middle Name

Last Name*


Mailing Address:*

City:*

State:*

Country:*

ZipCode:*

Home Phone Number:*

Work Phone Number:

E-Mail Address:*

Date of Birth:*

Sex:*

What is your native language?*

/ /

If English is not your native language, what percent of the day (on average) do you speak English?

%

Occupation:*

Employer:*

Highest Grade Completed:*


YOUR SPEECH:

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

Hypnosis

Air Flow

Metronome

Articulation

Psychiatric Treatment

Counseling or Psychology

Relaxation

Delayed Auditory Feedback

Slowed Speech

Desensitization  

 

FAMILY HISTORY OF STUTTERING:

Please list all family members, living or deceased, who stuttered. State their relationship to you (brother, uncle, sister, etc.), and their stuttering severity (mild, moderate or severe).

Family Member

Living/Deceased

Severity

 

YOUR HEALTH:

How do you rate your general health condition?*       Excellent     Good     Fair     Poor  


If you checked " Fair " or " Poor, " please explain   


Have you received a diagnosis from a medical provider or do you receive professional services for any of the following? Please check all that apply and include any medication, along with your dosages.

Medically Diagnosed Conditions:
Check all that apply
Provide any medications(s) and dosage(s) you are taking for conditions you checked

    Anxiety

   ADD/ADHD

   Auditory Processing Disorder

   Autism Spectrum disorders

   Bipolar Disorder

   Cerebral Palsy

   Chronic Respiratory condition

   Closed Head Injury/Traumatic Brain Injury

   Cluttering

   Cognitive difficulties

   Dementia/Memory disorders

   Depression

   Down´s syndrome

   Dysarthria

   Hearing Loss/Chronic Ear Infections

   Manic Depression

   Mood Disorder

   Muscular Dystrophy

   Multiple Sclerosis

   Obsessive Compulsive Disorder

   Parkinson´s Disease

   Personality Disorder

   Post-Traumatic Stress Disorder

   Reading comprehension difficulty

   Seizure Disorder

   Spasmodic Dysphonia

   Stroke (or history of mini-strokes)

   Substance abuse

   Surgeries or injuries
to mouth, tongue, jaw,
vocal folds (head & neck region)

Is there any other condition or information you would like to call to our attention?




Please enter security code:


Security code: