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:

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YOUR SPEECH:

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YOUR HEALTH:

                   

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

List any medications you are presently taking.

FAMILY HISTORY OF STUTTERING*

List family members, living or deceased, who stutter or stuttered. State their relationship to you, which side of the family they represent, and their stuttering severity (mild, moderate or severe).

Add Family Member Description
Sibling, Parent, Uncle/Aunt, Grandparent, etc.
Side of Family Represented
Maternal or Paternal
Stuttering Severity
Mild, Moderate or Severe
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