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If you would like to apply to attend a 4-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. 

All information is strictly confidential and your privacy is ensured.

You will receive a response within a week. If a vacancy is available on your chosen course we will request a deposit of $385 to confirm your place on that course.

* required - you must fill in these fields

Mild      Moderate      Severe
Mild      Moderate      Severe
Mild      Moderate      Severe
Low      Medium         High
Yes No
Have you been diagnosed with any of the following?:
Yes      No
Yes      No
Yes      No
Yes      No
Yes      No
Yes      No

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Lack of motivation
Failure to work hard enough
No or inadequate follow-up support
Inadequate guidance
Lack of personal power from therapist
Other reasons


Internet search engine
Television?
Radio?
Newspaper or magazine article?
Newspaper or magazine advertisement?
Yellow pages?
Speech therapist
Psychologist
Medical doctor?

Yes      No

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