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Apply Now

If you would like to apply to attend a 3-day intensive course please complete and send the following application form. The information will help us to provide the best possible treatment for you. All information is strictly confidential.

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All information is strictly confidential and your privacy is ensured.

You will receive a response within a week.

* required – you must fill in these fields
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First Name*required

Last Name*required

Home Address*required

City / County*required

Postcode/Eircode*required

Email address*required

Home Phone Number

Mobile Number*required

Date of Birth*required

Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Month January February March April May June July August September October November December Year Year 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Highest Level of Education:*required

Primary/First School High School College University Post Grad

Marital Status:*required

Single Cohabiting Married Divorced Widowed Other

Occupation:*required

Name & Telephone Number of emergency contact (next of kin)*required

How do you view your stutter?*required

Mild

Moderate

Severe

Interference in social life:*required

Mild

Moderate

Severe

Interference in career:*required

Mild

Moderate

Severe

Motivation to overcome it?*required

Low

Medium

High

Any physical disabilities?*required

Yes

No

Have you been diagnosed with any of the following?

Major mental illness*required

Yes

No

Dyslexia*required

Yes

No

Drug Addiction*required

Yes

No

Learning disability*required

Yes

No

Alcoholism*required

Yes

No

Autism*required

Yes

No

Aspergers Syndrome*required

Yes

No

Are you currently on any medication?*required

Yes

No

Tell us about your sports and hobbies*required

What other speech or speech related psychotherapy have you had?

Type of therapy

Dates of therapy

Methods used

Results

What therapy worked the best for you and why?

Why do you think the other therapies didn't work for you? *required

Lack of motivation

Failure to work hard enough

No or inadequate follow-up support

Inadequate guidance

Lack of personal power from therapist

Other reasons

What do you hope to gain from our programme? *required

What do you want to do that requires good speaking ability? *required

How did you hear about the McGuire Programme?Please select option(s)

Internet search engine

Facebook

Twitter

Google+

Television

Radio

Newspaper or magazine article

Newspaper or magazine advertisement

Speech therapist

Psychologist

Medical doctor

Website

Support Group

Friend/Colleague

In which of these upcoming courses would you like to apply to?*required

Galway - June 26.-29.2019 Cork - Oct 16.-19.2019 Dublin - February 26.-29.2020 Galway - June 24.-27.2020

Type the characters*required

This field should be left blank

Send Application Form

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