Application Form

Complete our form to apply to join the SHB program. Be coached to a life of freedom and no holding back!

ABOUT YOU

How did you hear about us?

Do you have any other disabilities?

Do you currently or have you ever suffered with any mental health issues? If yes, please describe

Do you or have you previously suffered with drug addiction? If yes, please describe.

Please list any therapies you have had or courses you have attended that relate to your stuttering or any other issues that are relevant. Describe how these helped or did not help and why

MORE ABOUT YOU

Did you consider yourself to be academic when you were at school?

Do you participate in or follow sport? If yes, please list the sport along with an explanation of the level you have played at.

Lists some hobbies or interest you have. How many hours weekly do you spend on your hobbies?

Please explain, in your own words, your understanding of the difference between a covert stutterer and an overt stutterer.

Do you consider your lifestyle to be busy? If yes, please explain why.

At the moment how many hours do you feel you can dedicate to working on your speech each week?

Generally, are you comfortable to talk to people about your stutter? If no, explain why not.

Have you ever been bullied for any reason? If so, please explain.

Do you feel that you have experience discrimination as a result of having a stutter? If so, where and when?

What is your marital status? Text box to answer.

Describe in a few words, some emotions that you feel when you are blocking.

List 3 things you feel you would be doing in life if you did not have a stutter.

LIFE AT WORK

*If you are currently unemployed please skip this section of the form.

How willing are you to take on new responsibilities at work? Explain the reason for your answer.

How many hours do you work a week and what shift pattern do you work?

Who is it that you find is most difficult when talking to at work?

Are you currently in the job of your dreams or is there a job you would switch to immediately if you felt you could? If so, what would that job be?

Please explain how your stutter affects you at work?

LIFESTYLE

Do you have any aspirations do you give public speeches? Yes/no please explain the reason for your answer.

Do you aspire to become a better communicator? If yes, explain why.

ABOUT YOUR STUTTERING

Explain what is going on in your mind when you are experiencing a severe block

Do you experience any physical pain when you are blocking? If so, please describe.

Which sounds do you avoid most or find most difficult to say?

Please describe any situations where you avoid or have avoided because you stutter.

Do you ever experience periods of fluency? If so, how long are these periods for?

TRUE OR FALSE TEST

Directions:

Choose TRUE for each statement that is true or mostly true for you and choose FALSE for each statement which is false or not usually true for you.

FAMILY AND SOCIAL RELATIONSHIPS

Describe the relationship you have with your family?