Student's form - Anatomy of Stuttering
strictly confidential / please reply to all the questions.
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Email *
Your name and surname *
Age *
What level of participation do you select? *
Your level of education  *
When did you start stuttering? *
How long have you been stuttering? *
What will fluency help you achieve in life? What is your BIGGER goal in life? What then? *
Why have you chosen me as your fluency coach? *
Why do you need help now?  *
On the scale of 1 (not at all) to 10 (extremely), how important it is for you to solve the problem ?  *
not important, life is good
critically important, life is affected badly
How does the problem affect (or restrict) your life at the moment?  *
What therapy have you tried before? *
In your opinion, what stops you from reaching freedom now? What blocks your progress? *
What do you know about stuttering? *
My coaching will require your active participation and time, do you have these available for working on your speech and self? *
How will you know that you are improving? What is your success criteria? What will you be able to do? (i.e record a voice message, present etc) Please state at least 5 activities. *
During the course, students will require to record short video reports, are you agree to do it? (videos will not be made public) *
Recovery is a gradual process. You understand that blocking/stumbling in early stages DOES NOT equate to "failure", you will not despair, or drop out from the course? *
All my programmes are practical, are you ready to experiment?  *
Do you have any psychological disorders (manic disorder, OCD, diagnosed depression, suicidal tendencies, schizophrenia etc) *
Anything else I need to know about you before the start of the programme? *
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