This evaluation form will enable the TalkPower staff to evaluate your speech phobia and determine whether the TalkPower program will be helpful.  Please be sure to provide at least one method by which to contact you.

(All information entered is kept confidential) 

Name *
Symptoms you experience before, during, or after speaking in public.
Check all that apply
Please check the appropriate boxes.
Please briefly describe:
I have tried in the past to get help for this problem at:
Free telephone diagnostic evaluation?
I would like a free telephone diagnostic evaluation Please indicate the best time for you to be called so that we may set up an appointment for a free telephone evaluation.
If you have any questions please feel free to write them here and one of our staff will discuss them with you in your phone interview.