SLP-Assistant Application: Associates in SLP-Assisting

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Step 1 of 3

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Please note: SLP-Assistants in North Carolina are only authorized to serve the caseload of their Primary Supervisor(s). SLP-Assistants are registered under an actively licensed Speech-Language Pathologist in North Carolina. The Primary Supervisor is fully responsible for the SLP-Assistant, not the employer.

Assistant Information

If your degree is a B.A./B.S., or you are coming from another state please do not proceed with this application. Please use the SLP-Assistant: Bachelor’s Degree/Out-of-State Application.

SLP-Assistant Associates in Applied Science Applicant*

I understand that by continuing with this application I certify that I hold a degree in Associates of Applied Sciences in Speech-Language Pathology Assisting. I understand if I hold a bachelor’s degree, or I have experience in another state as an slp-assistant and continue with this application I understand there will be a delay because I did not use the SLP-Assistant: Bachelor’s Degree/Out-of-State Application.

Name*

Prefix First Middle Last

Other names you have used

Include maiden name; add as many as apply.

Address*

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

Phone*

This number is:

Home

Cell

Phone (other)

Email*

Social Security Number or Individual Tax ID Number*

Date of Birth*

MM slash DD slash YYYY

Exam Choice*

If you change your mind after this submission, you will need to notify the Board office.

I have taken the NC SLP-Assistant Exam

I will be taking the NC SLP-Assistant Exam

I will be taking the ASHA SLP-Assistant Exam

Education

List each degree adding as many rows as necessary*

Institution Name

City/State

Major Field of Study

Type of Degree Received

Date Conferred

21 CAC 64 .1002 GENERAL REQUIREMENTS

(1) For registration, Assistants must present:

evidence of successful completion of an Associate’s Degree in Speech-Language Pathology Assisting from an accredited institution of higher learning, community college, or equivalent program. Official transcripts may be emailed directly from the training program to the Board to enewman@ncboeslpa.org ; OR
evidence of successful completion of a Bachelor’s Degree from an accredited institution as well as a passing score on the N.C. SLP-Assistant Jurisprudence Exam. Official transcripts may be emailed directly from the training program to the Board to kyoung@ncboeslpa.org

(2) a passing score on a competency test approved by the Board.

(3) The SLP-Assistant Registration documents completed and signed by the SLP-Assistant and supervising licensee(s). This packet includes all of the following:

Applicant Information form
Knowledge Demonstration for Licensed Speech-Language Pathologists to register a SLP-Assistant.
SLP-Assistant Protocol Target Behavior Form- filled out and signed by both the SLP-Assistant and supervising licensee.
Official transcripts with degree(s) conferred (Must be Printable if sent by official School email).
Official letter(s) of verification from ‘other states (if applicable).
SLP-Assistant Registration fee $40.00*

*If payment is made by personal or business check, it must clear the mandatory 10-day hold from day of deposit before documents will be mailed out. Deposits are typically made on Fridays. These fees may also be paid by money order, cashier’s check/bank check, or on our website through Pay Pal.

Do you have experience in another state as an SLP-Assistant*

If you have been registered or licensed as a Speech-Language Pathology Assistant in another state, you will need to provide a letter of verification from the state where you have most recently provided services. This letter of verification must come directly from the other state board’s office to the NC board’s office. They may be sent electronically to kyoung@ncboeslpa.org.

Yes

Email print version of completed form

Would you like a PDF version of this completed form emailed to you?*

Yes

Email (for PDF delivery)*

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

Transcript Submission*

I have requested my Official Transcripts be mailed to the Board’s PO Box

I have requested my Official Transcripts be emailed to kyoung@ncboeslpa.org

Has disciplinary action ever been taken against you by a licensing board or professional agency?*

Yes

Have you submitted an Application to be an NC SLP-Assistant in the past?*

Yes

By signing I understand that I may not obtain clinical fieldwork hours/provide services as a SLP Assistant until my supervising SLP and I have completed the application and registration process for a temporary registration/registration and I receive my temporary registration/ registration number and official notification from the Board that my registration has been issued. Completing clinical fieldwork hours/ providing services as and SLP Assistant without properly registering with the Board violates NC 901-301 A .(2) and may be subject to discipline.*

I understand that I may not obtain clinical fieldwork hours/provide services as a SLP Assistant until my supervising SLP and I have completed the application and registration process for a temporary registration/registration and I receive my temporary registration/ registration number and official notification from the Board that my registration has been issued. Completing clinical fieldwork hours/ providing services as and SLP Assistant without properly registering with the Board violates NC 901-301 A .(2) and may be subject to discipline.

Application Attestation*

By signing this application, I certify that all information provided is true and accurate to the best of my knowledge. I understand, am in compliance with, and have reviewed and understand Article 22 and the Administrative Code 21 NCAC 64.

"*" indicates required fields

Step 1 of 3

33%

Assistant Information

If your degree is a B.A./B.S., or you are coming from another state please do not proceed with this application. Please use the SLP-Assistant: Bachelor's Degree/Out-of-State Application.

SLP-Assistant Associates in Applied Science Applicant*

I understand that by continuing with this application I certify that I hold a degree in Associates of Applied Sciences in Speech-Language Pathology Assisting. I understand if I hold a bachelor's degree, or I have experience in another state as an slp-assistant and continue with this application I understand there will be a delay because I did not use the SLP-Assistant: Bachelor's Degree/Out-of-State Application.

Name*

Prefix First Middle Last

Other names you have used

Include maiden name; add as many as apply.

Address*

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

Phone*

This number is:

Home

Cell

Phone (other)

Email*

Social Security Number or Individual Tax ID Number*

Date of Birth*

MM slash DD slash YYYY

Exam Choice*

If you change your mind after this submission, you will need to notify the Board office.

I have taken the NC SLP-Assistant Exam

I will be taking the NC SLP-Assistant Exam

I will be taking the ASHA SLP-Assistant Exam

Education

List each degree adding as many rows as necessary*

Institution Name

City/State

Major Field of Study

Type of Degree Received

Date Conferred

21 CAC 64 .1002 GENERAL REQUIREMENTS

(1) For registration, Assistants must present:

evidence of successful completion of an Associate's Degree in Speech-Language Pathology Assisting from an accredited institution of higher learning, community college, or equivalent program. Official transcripts may be emailed directly from the training program to the Board to enewman@ncboeslpa.org ; OR
evidence of successful completion of a Bachelor's Degree from an accredited institution as well as a passing score on the N.C. SLP-Assistant Jurisprudence Exam. Official transcripts may be emailed directly from the training program to the Board to kyoung@ncboeslpa.org

Applicant Information form
Knowledge Demonstration for Licensed Speech-Language Pathologists to register a SLP-Assistant.
SLP-Assistant Protocol Target Behavior Form- filled out and signed by both the SLP-Assistant and supervising licensee.
Official transcripts with degree(s) conferred (Must be Printable if sent by official School email).
Official letter(s) of verification from 'other states (if applicable).
SLP-Assistant Registration fee $40.00*

*If payment is made by personal or business check, it must clear the mandatory 10-day hold from day of deposit before documents will be mailed out. Deposits are typically made on Fridays. These fees may also be paid by money order, cashier's check/bank check, or on our website through Pay Pal.

Do you have experience in another state as an SLP-Assistant*

If you have been registered or licensed as a Speech-Language Pathology Assistant in another state, you will need to provide a letter of verification from the state where you have most recently provided services. This letter of verification must come directly from the other state board's office to the NC board's office. They may be sent electronically to kyoung@ncboeslpa.org.

Yes

Email print version of completed form

Would you like a PDF version of this completed form emailed to you?*

Yes

Email (for PDF delivery)*

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

Transcript Submission*

I have requested my Official Transcripts be mailed to the Board's PO Box

I have requested my Official Transcripts be emailed to kyoung@ncboeslpa.org

Has disciplinary action ever been taken against you by a licensing board or professional agency?*

Yes

Have you submitted an Application to be an NC SLP-Assistant in the past?*

Yes

Application Attestation*

Proposed Rule Change (NCBOESLPA) – Supervision of SLP-Assistants view announcement

Assistant Information

Education

21 CAC 64 .1002 GENERAL REQUIREMENTS

Email print version of completed form

Assistant Information

Education

21 CAC 64 .1002 GENERAL REQUIREMENTS

Email print version of completed form

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