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APPLICATION FOR A STARFISH COURSE

Please answer all questions as frankly and honestly as possible.

Your answers are handled in the strictest confidence and are to assist us in helping you on a course.

* denotes a required field

Your Details
Name*
Date of Birth* e.g. 26/03/1969
Age*
Gender*
Marital Status*
Address*
Postcode*
Telephone Home*
Telephone Work
Mobile Number
Email Address*
Occupation

Your telephone number is very important to us, as we need to discuss your course with you. PLEASE ENSURE YOU INSERT IT ABOVE.

We do appreciate that the telephone is a problem for some people who stammer. However, please remember that we speak to more people who stammer, applying for a Starfish course, than people who do not. We are only interested in what you have to say, not how you say it.

Please answer all questions as frankly and honestly as possible, your answers are handled in the strictest confidence and are to assist us in helping you on a course.

About You
The severity of your stammer?
Interference in your social life of your stammer?
Interference in your career of your stammer?
Are you motivated to overcome stammering?
Do you have any physical disabilities
If yes, please describe
Any major Physical Illness?
(e.g. Heart or Lung Disease)
If yes please elaborate
Is there anything else about you or your health that you believe we will need to know?
Previous Therapies / Date / Method(s) used
Date (e.g. 26/03/1969)
Name of Therapy/Method used
Date (e.g. 26/03/1969)
Name of Therapy/Method used
Which of these therapies worked for you and why?

Why do you think other therapies didn't work for you? (please tick any relevant boxes)

 
 
 
 
 
 
 
Is there anything else about you that you feel is relevant?
How did you hear about The Starfish Project?

To enable us to reach more people who stammer could you please tell us, how you heard about The Starfish Project ?




Other contact please tell us
Prefered Course Dates

Starfish Project Courses are held regularly throughout the year. To enable us to schedule a suitable date for you please let us know dates that you are available for a course. We will then discuss a mutually convenient time with you.

MY FIRST choice * The most suitable course date for me would be.
Alternative / MY SECOND choice *     Or
 

I WOULD LIKE A COURSE AS SOON AS POSSIBLE PLEASE NOTIFY ME. I can arrange to attend a course at short notice. Please Click on the box at the start of this sentence.

Sometimes a course place is available at short notice, we will contact you if a place becomes available.

Application confirmation

I wish to apply for a place on a intensive therapy course organised by The Starfish Project.
I confirm that I have read and understood the literature provided to me by The Starfish Project and that the information that I have provided will be treated in the strictest confidence by The Starfish Project.
I appreciate that though The Starfish Project has had a beneficial effect for other stammerers , it offers no guarantee of recovery from or a cure for stammering. The Starfish Project will not be responsible for any direct or consequential effects which may arise from my participation in its programme.

Your Name:*
In the case of a Young Person Name of Parent/Guardian
Today's Date:*
Please check the box opposite and answer the security question.

PLEASE CLICK ON THE SUBMIT BUTTON BELOW TO COMPLETE YOUR APPLICATION