Starfish Course Application Form

Supportive Training and Recovery For Individual Stammerers Harmony

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*

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.

About You

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.

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

Name of Therapy/Method used

Date

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)

1. Lack of motivation

2. I did not work hard enough at it

3. Inadequate guidance

4. Lack of personal power from the therapist

5. Absence of follow-up support

6. Other reasons (please list in the box below)

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 ?

World Wide Web

Newspaper / Magazine Article (Name the Newspaper or Magazine below)

British Stammering Association

Referral by Therapist / Recommended

Recommended by A Friend

Radio - T.V. (Name the Radio / TV programme or Radio / TV station below)

Other contact please tell us

Preferred 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 *

I WOULD LIKE A COURSE AS SOON AS POSSIBLE, PLEASE NOTIFY ME.
I can arrange to attend a course at short notice. Please Tick 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.

Covid 19 safety measures on Starfish Project courses

To protect the health of everyone on a Starfish course we have sought professional health and infection control advice. Based on that advice, we have implemented various safety measures for the safety of everyone on a course. Everyone attending a Starfish residential course will be required to have received both 1st and 2nd Covid vaccinations, with the 2nd vaccination received a minimum of 14 days before the course start date. Everyone will be required to show proof of their vaccinations either electronically (with the NHS app), or a doctor’s letter confirming the vaccinations. Everyone will be required to follow the safety measures on a course for our mutual protection.

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.