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Tell Us More About How Can We Help You

Patient Full Name *

Patient Age *

Your Name (if different) and relationship to patient

Email *

Phone *

By providing my phone number, I agree to receive appointment reminder text messages from Stutter.Help.

Why are you applying to the Stutter.Help program? *

What have you done so far to address this? *

What is going to be different in your life as a result of achieving this goal? *

What has been holding you back from making this change? *

How ready to change are you on a scale of 1 to 10? (Where 10 means you'll stop at nothing to acheive this.) *

Why now? What has changed that makes you feel like now is the time to reach out to our clinic? *

I understand that programs begin at $5000, and I’m willing to make that kind of investment in myself. *

What else should we know so that we can help you best? *