SLP-Assistant Supervision Changes

Cost: $20
Assistant Information
Name*
Prefix First Middle Last
Registration Number*
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone*
Reason for Change*
- SLP-Assistant will no longer work under previous supervisor
- This is additional employment. SLP-A will continue to work under previous Primary Supervisor as well.
SLP-Assistant’s hours per week under this supervision*

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Primary Supervisor Information
Primary Supervisor*
Prefix First Middle Last
NC License Number*
Number of other SLP-Assistants the Primary Supervisor is the primary supervisor for.*
This # is not including this SLP-Assistant.
Number of hours the Primary Supervisor works per week.*
Secondary Supervisor Information
Secondary Supervisor
Prefix First Middle Last
NC License Number
Number of other SLP-Assistants the Secondary Supervisor is the secodary supervisor for.
This # is not including this SLP-Assistant.

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Employer Information
Employer Name*
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Service Locations*
Provide the exact location where SLP-A will provide services. If in homes, list the areas such as towns or counties of the homes. Daycare names and addresses are required.

Street Address Address Line 2 City State ZIP Code
Are there multiple locations where services will be provided?*
- Yes
- No
Additional Locations
Please list any additional locations where services will be provided.

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SLP-Assistant Protocol Target Behavior Form
Attach completed SLP-Assistant Protocol Target Behavior Form*
Download form here to be completed and submitted with this application.
Performance-Based Competency Assessment & Orientation Checklist for SLP-Assistants
Download form here to be completed and submitted within 90 days from the date of registration or supervision change.
Requirements for registering a SLP-Assistant*
I have read and understand the Requirements for Registering a SLP-Assistant
I have.
Supervisor & Assistant Consent & 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 SLP-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 Applicant*
Date
Date Format: MM slash DD slash YYYY
To be completed by the Primary Supervisor
As supervisor of the above listed applicant, 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 understand that as the supervisor, I accept responsibility for the professional services carried out by this SLP-Assistant. I understand that I or the above named Secondary Supervisor if one is listed, must be within 50 miles of the SLP-Assistant while he or she is providing services. I also certify that all information in this application is correct.
Signature of Supervisor*
Please print this file from the PDF that is emailed to you and have your supervisor sign here.
Email print version of completed form
Would you like a PDF version of this completed form emailed to you?*
- Yes
- No
Email (for PDF delivery)
Please enter an email address to receive a copy of this completed form.
SLP-Assistant Supervision Changes Fee
Convenience Fee

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Step 1 of 5

Cost: $20

Assistant Information

Primary Supervisor Information

Secondary Supervisor Information

Employer Information

Quiz

SLP-Assistant Protocol Target Behavior Form

Performance-Based Competency Assessment & Orientation Checklist for SLP-Assistants

Supervisor & Assistant Consent & Signatures

To be completed by the SLP-Assistant

To be completed by the Primary Supervisor

Email print version of completed form

Licensure & Listing