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Phone  855-236-7032
Leaders in Effective Stuttering Therapy
12-Day Immersion Therapy – Invented Here at HCRI

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. HCRI stuttering therapy is held in Roanoke, Virginia and is designed for people ages 11 and up. 

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

Phone Number:*

E-Mail Address:*

Date of Birth:*

Sex:*

/ /

Male Female

Occupation:*

Employer:

Highest Grade Completed:*



YOUR SPEECH:

At what age did you begin to stutter?*


What is your Native Language*

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

%

How would you describe the severity of your stuttering?*


Have you participated in other forms of stuttering therapy in the past?*

YES NO

Do you have a parent or sibling in your family who stutters? *

YES NO



YOUR HEALTH:

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

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

    Anxiety

   Apraxia

   ADD/ADHD

   Auditory Processing Disorder

   Autism Spectrum disorders

   Cerebral Palsy

   Closed Head Injury/Traumatic Brain Injury

   Cluttering

   Cognitive difficulties

   Dementia/Memory disorders

   Down´s syndrome

   Hearing Loss/Chronic Ear Infections

   Mood Disorder

   Muscular Dystrophy

   Multiple Sclerosis

   Obsessive Compulsive Disorder

   Parkinson´s Disease

   Personality Disorder

   Reading comprehension difficulty

   Seizure Disorder

   Stroke (or history of mini-strokes)

   Substance abuse

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

List any medications you are presently taking.




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