TALK POWER INC.

SPEAK WITHOUT FEAR...TALK POWER PUBLIC SPEAKING TRAINING SEMINARS

This evaluation form will enable the TalkPower staff to evaluate your speech phobia and determine whether the TalkPower program will be helpful.

Name:
Address:
City:
State:
Zip:
E-mail Address:
Phone (home):
Phone (work):
Occupation:

Please check off the specific symptoms you experience before, during, or after speaking in public.

Thought blocking Rapid heartbeat
Rapid speech Hyperventilation
General disorganization Feelings of terror
Loss of memory Feeling faint
Loss of control Intense anxiety
Feelings of embarrassment Tension in chest
Feelings of humiliation Feeling dizzy
Wobbly voice Feeling helpless
Tension in legs Tight throat
Phlegm in throat Trembling knees
Eye tearing Trembling voice
Tension in neck Other

Please check the appropriate boxes.

I speak
I avoid speaking
A combination of both
I have had this problem as far back as I can remember
This problem began for me when:

 

My advancement has been negatively affected because of my discomfort about speaking in public
Not affected
Other (explain)

 

I feel that there must be something or someone out there who can help me
I feel I am totally hopeless about getting any help for this problem
I feel deeply motivated to do something about this problem
I have never taken any course or worked with anyone to overcome this problem
I have tried in the past to get help for this problem at:

 

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.