Courses & Support
For Adult Stammerers

"Application Form"

Application Form to attend a Changes Course

All applications are treated in the strictest of confidence.

The application is split into different sections:

1) Personal Details

2) Health Details for your wellbeing and safety on our courses.

3) Details about you stammer and your goals

4) Details about any previous therapy you have had for your speech.

All the details will be kept private and confidential and used to help support you on the courses.

In the application form we also ask about any goals or achievements you would like to accomplish as a result of attending this course. Please Consider both short-term and long-term goals, including situations you’ve avoided or found challenging due to your speech.

When thinking about your goals, remember that these are your personal goals. No two people are the same, and everyone’s aspirations are equally valid. For one person, a goal might be pursuing a career as an actor or thriving in a high-powered role. For another, it could be confidently ordering the correct drink at a coffee shop, reading bedtime stories to their children, or comfortably ordering a round of drinks at the pub.

There’s no comparison — this is about what’s important to you and what you want to achieve. Every goal matters, no matter how big or small it may seem.

This will also be a great reference to look back on, celebrating achievements and setting new goals along the way.

Take your time and be honest about what would make a difference in your life. You can always add why it’s a goal or what it means, if you feel that would be helpful to look back over.

Title Mr/Mrs/Miss*

This field is mandatory

Full Name*

This field is mandatory

Preferred name

Gender*

This field is mandatory

Date of Birth*

This field is mandatory

Age*

This field is mandatory

I am over 18*

This field is mandatory

Martial Status

Address*

This field is mandatory

Postcode*

This field is mandatory

Mobile*

This field is mandatory

Landline

E-mail*

This field is mandatory

The e-mail address is invalid

Occupation

Emergency Contact details: Please give details of the person who should be contacted in case of an emergency. Name, Contact number and relationship to you.*

This field is mandatory

Health Conditions. Do you have any medical conditions that we should be aware of to ensure your safety and comfort during the course?*

This field is mandatory

Allergies: Do you have any allergies, including food, medication or environmental that we need to be aware of to ensure your safety and comfort during the course?*

This field is mandatory

Do you carry an EpiPen or require any emergency medication?*

This field is mandatory

Is there anything we can do to support your health and well-being during the course?*

This field is mandatory

Do you have any accessibility needs? *

This field is mandatory

Are you currently taking any medication that we should be aware of incase of an emergency?*

This field is mandatory

Would you say your stammer is mild, moderate or severe

At what age did you start stammering?

What is your earliest memory of stammering?

Do have have memories of stammering at school?

Does stammering affect your social life? If so, how would you say it affects and impacting you?*

This field is mandatory

Does stammering affect your working life/choice of career? If so in what ways would you say it affects & impacts you?*

This field is mandatory

Is there anything else that you want to add about how stammering is affecting & impacting you?

Are there any specific words or sounds that you feel you find more difficult?

What situations do you find the most difficult?*

This field is mandatory

Do you use any strategies, behaviours or what some people call tricks to help you to cope with stammering. For example: filler words, filler sounds like um, er, mmm, leg/tapping, head nodding etc...

How did you hear about the "Changes" courses?*

This field is mandatory

What motivated you to apply for the course?*

This field is mandatory

What would you like to achieve by attending this course?*

This field is mandatory

Goals Please list any goals or achievements you would like to accomplish as a result of attending this course. Consider both short-term and long-term goals. * More details below about goals.*

This field is mandatory

Please list any previous therapy or courses you have attended. Provide approximate dates, what was taught, and what aspects you found helpful or unhelpful.*

This field is mandatory

Why do you think other therapies have or haven't work for you?

If you have any additional comments or information you feel may be helpful please add here.

I understand that this course is not a cure.*

This field is mandatory

I understand that this course teaches a technique that helps to control stammering, it needs to be practiced and everybody works at their own pace. I understand that there are no guarantees.*

This field is mandatory

I hereby agree that the information provided in this application form will be stored and processed for the purpose of assessing my application, managing my participation in the course, and maintaining contact regarding this course and any future courses that may be relevant. I understand that I can revoke my consent at any time.*

* Indicates required fields

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Thank you! We will get back to you as soon as possible.

Thank You

Thank you for completing this form.
Your responses will help us to understand your previous experiences and goals,
and how we can best support you on our courses.
We will be back in touch with you as soon as possible,

Courses & SupportFor Adult Stammerers

"Application Form"

Application Form to attend a Changes Course

Thank YouThank you for completing this form. Your responses will help us to understand your previous experiences and goals, and how we can best support you on our courses. We will be back in touch with you as soon as possible,

“Changes"Courses and Support forAdult Stammerers.

Courses & Support
For Adult Stammerers

Thank You

Thank you for completing this form.
Your responses will help us to understand your previous experiences and goals,
and how we can best support you on our courses.
We will be back in touch with you as soon as possible,

“Changes"

Courses and Support for
Adult Stammerers.