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Effective Stuttering Therapy – in 12 days
855-236-7032      info@stuttering.org
Award-Winning Pioneers in Stuttering Therapy

Submit Your HCRI Therapy Application

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, 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 for participation in HCRI's therapy program.

GENERAL INFORMATION:

First Name*

Middle Name*

Last Name*

Mailing Address:*

Date of Birth:*

//

City:*

Sex:*

State:*

Native Language:*

Country:*

Occupation:*

ZipCode:*

Employer:*

Home Phone Number:*

Highest Grade Completed:*

Work Phone Number:

E-Mail Address:*

 

 

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.), 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:

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 for or do you receive professional services for any of the following?

Condition No Yes If yes, do you take
medicine for this?
If yes, provide medication name(s) and dosage(s). Also, tell
us more about your condition in the space provided.

Anxiety

 No    Yes  

Apraxia

 No    Yes  

ADD/ADHD

 No    Yes  

Auditory Processing Disorder

 No    Yes  

Autism Spectrum disorders
(including Asperger ´s or Pervasive
Developmental Disorder)
 No    Yes  

Bipolar Disorder

 No    Yes  

Cerebral Palsy  No    Yes  

Chronic Respiratory condition

 No    Yes  

Closed Head Injury/Traumatic Brain Injury

 No    Yes  

Cluttering

 No    Yes  

Cognitive difficulties  No    Yes  

Dementia/Memory disorders  No    Yes  

Depression

 No    Yes  

Down´s syndrome  No    Yes  

Dysarthria

 No    Yes  

Dyslexia

 No    Yes  

Hearing Loss/Chronic Ear Infections  No    Yes  

Manic Depression  No    Yes  

Mood Disorder  No    Yes  

Muscular Dystrophy  No    Yes  

Multiple Sclerosis  No    Yes  

Obsessive Compulsive Disorder  No    Yes  

Parkinson´s Disease  No    Yes  

Personality Disorder  No    Yes  

Post-Traumatic Stress Disorder  No    Yes  

Reading comprehension difficulty  No    Yes  

Seizure Disorder  No    Yes  

Spasmodic Dysphonia  No    Yes  

Stroke (or history of mini-strokes)  No    Yes  

Substance abuse  No    Yes  

Surgeries or injuries to mouth, tongue, jaw,
vocal folds (head & neck region)
 No    Yes  

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


For our research purposes, please indicate whether you are:*       Right Handed   Left Handed     Ambidextrous  


Please complete the following sentence:

The Color of the Sky Is     (Hint: It's four letters and is a color)
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