Temporary SLP-Assistant Registration Form 2.0

Cost: $40 (+$3 for PayPal)

Who can fill out this form?*

This form may only be completed by the SLP requesting the below listed SLP-Assistant to be added to their license. This form may not be completed by another SLP, SLP-Assistant, or Office Staff.

By signing I certify that I, the potential supervising SLP for this registrant is completing this form as required by Article 22. If this form is not signed properly, it will be denied.

Supervisor Information

Primary Supervisor*

Prefix First Middle Last

NC License Number*

Primary Supervisor's Email*

Enter Email Confirm Email

How many SLP-Assistants do you currently supervise?*

This should include all SLP-Assistant(s) that you supervise, under other licenses/registrations you may hold in other jurisdictions. This also includes if you are the secondary supervisor for any SLP-Assistant(s).

None

One

Two or more

Assistant Information

Name*

Prefix First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary/Mobile Phone*

Work

Assistant's Email*

Enter Email Confirm Email

Academic Information

College/University Information*

Training Program

Major

Degree

Date

SLP-Assistant Exam Date

Please select the date the exam was passed by the applicant, if they have taken their exam.

Employer Information

Employer Name*

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Service Locations*

Street Address Address Line 2 City State ZIP Code

Additional Service Locations*

Are there multiple locations where services will be provided?

Yes

No

Additional Locations*

Please list any additional locations where services will be provided. Complete names and addresses are required for business, schools, Head Start Programs, and daycares.

If services are being provided in homes, please provide the city and/or county in which the homes are located. For those cases please state they are, "home locations in City/County".

To add rows use "+".

Primary Supervisor Attestations

These may only be completed by the SLP requesting the above listed SLP-Assistant to be added to their license. This may not be completed by another SLP, SLP-Assistant, or Office Staff.

Assistant Sample Protocol Target Behavior Form

Attach completed SAMPLE SLP-Assistant Protocol Target Behavior Form THIS HAS TO BE SIGNED AND COMPLETED AS IT WOULD BE FOR A REAL PATIENT/ CLIENT*

Download form here this is the SLP-Assistant Protocol Target Behavior form, you must complete a sample of this form as you would for a patient/client your SLP Assistant would be providing services for. This is to show the Board you understand how to complete the form properly. Please attach the sample below. Once the SLP Assistant is approved under your license this specific form is required to be completed by the Primary supervising SLP for EACH patient/client based on that clients specific needs/ goals that the SLP Assistant will be using to meet the goals with. Each patient/client's target behavior form will need to remain in their file until a new one is created based on the clients current status and goals . The Primary SLP will need to evaluate the patient/client and fill out a target behavior form for that patient/client before the SLP Assistant begins providing services and using the target behavior form. These forms are subject to Board audit at any time. IF THE SAMPLE ATTACHED TO THIS REQUEST IS INCORRECT OR INCOMPLETE THE REGISTRATION WILL NOT BE ABLE TO BE APPROVED, AND YOU WILL BE REQUIRED TO RESUBMIT.

Max. file size: 50 MB.

Supervisor and Assistant Consent and Signatures

Click here to download Section .1000 -.1005 - Requirements for the Use of Speech-Language Pathology Assistants in Direct Service Delivery in North Carolina

To be completed by the Assistant

I have read Section .1000 -.1005 – of Article 22 – Licensure Act for Speech-Language Pathologists - Requirements for the Use of Speech-Language Assistants in Direct Service Delivery in North Carolina and Audiologists, and I agree to abide by all of its requirements. I also certify that all information provided in this application is correct.

Signature of Assistant*

Date*

To be completed by the Supervisor

As supervisor of the above listed applicant, I have read the Licensure Act for Speech-Language Pathologists and Audiologists including the Requirements for the Use of Assistants in Direct Service Delivery in North Carolina and I agree to abide by all of its requirements. I understand that as the supervisor, I accept responsibility for the professional services carried out by this Assistant. I also certify that all information in this application is correct.

Signature of Supervisor*

Date*

Notice

Any change in the above plan OR supervisor must be reported to the Board PRIOR to implementing the change or continuing the practice.

Upon Submission

Once the Board receives the completed paperwork and fee please allow up to 10 days for processing. To avoid processing delays, updates will not be provided in the duration of the 10 days. Once the request is approved you will receive and email confirming the change. Also, your portal and the website will reflect the approved change.

Email (for PDF form delivery)*

Please enter an email address to receive a copy of this completed form.

Enter Email Confirm Email

Payment Information

Payment Options*

Mail Payment with Printed Form

I want a PayPal invoice sent to the email for PDF delivery email address provided on this form (A $3 fee will be added for online payments)

OTC Hearing Aids and "Prescription" Hearing Aids Resource Page view page

Cost: $40 (+$3 for PayPal)

Supervisor Information

Assistant Information

Academic Information

Employer Information

Primary Supervisor Attestations

Quiz

Assistant Sample Protocol Target Behavior Form

Supervisor and Assistant Consent and Signatures

To be completed by the Assistant

To be completed by the Supervisor

Notice

Upon Submission

Payment Information