Speech-Language Pathologists and Audiologists Forms

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"An individual who completes and files this form with the Texas Department of Licensing and Regulation (the Department) is entitled to the following from the Department:

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Speech-Language Pathology Application

SPA006 Speech-Language Pathology Application (including ASHA Waiver) revised April 2017 (897KB PDF)

Assistant in Speech-Language Pathology

SPA007 Assistant in Speech-Language Pathology Application (545KB PDF)

SPA013 Speech-Language Pathology Supervisory Responsibility Statement (SRS) revised July 2017 (509KB PDF)

SPA017 Clinical Observation and Experience Form for Speech-Lanuage Pathology Assistant (53KB PDF)

SPA021 Assistant in Speech-Language Pathology Clinical Deficiency Plan (91KB PDF)

Intern in Speech-Language Pathology

SPA008 Intern In Speech-Language Pathology Application revised June 2017 (895KB PDF)

SPA012 Speech-Language Pathology Intern Plan and Agreement of Supervision revised October 2017 (436KB PDF)

SPA015 Speech-Language Pathology Report of Completed Internship Form revised October 2017 (86KB PDF)

SPA016 Intern in Speech-Language Pathology Course Work and Clinical Experience Form (84KB PDF)

Intern in Speech-Language Pathology Upgrade to Speech-Language Pathology

SPA010 Upgrade Intern in Speech-Language Pathology Application (88KB PDF)

SPA015 Speech-Language Pathology Report of Completed Internship Form (86KB PDF)

Audiology Application

SPA005 Audiology Application (including ASHA or ABA Waiver) (547KB PDF)

Assistant in Audiology

SPA001 Assistant In Audiology Application (543KB PDF)

SPA011 Report of Completed Training for an Assistant in Audiology (80KB PDF)

SPA018 Assistant in Audiology Supervisory Responsibility Statement (SRS) (47KB PDF) revised January 2017

Intern in Audiology

SPA002 Intern In Audiology Application (543KB PDF)

SPA014 Audiology Intern Plan and Agreement of Supervision (90KB PDF)

SPA019 Report of Completed in Internship in Audiology Form (70KB PDF)

SPA020 Intern in Audiology Course Work and Clinical Experience Form (51KB PDF)

Intern in Audiology Upgrade to Audiologist

SPA004 Upgrade Intern Audiologist Application (93KB PDF)

SPA019 Report of Completed in Internship in Audiology Form (74KB PDF)

Clinical Deficiency Plan

SPA017 Clinical Observation and Experience Form for Speech-Language Pathology Assistant (53KB PDF)

SPA021 Assistant in Speech-Language Pathology Clinical Deficiency Plan (91KB PDF)

SPA023 Assistant in speech-language Pathology Clinical Deficiency Plan Completion of Training and Rating Scale (74KB PDF)

SPA024 Assistant in Speech-Language Pathology Clinical Deficiency Plan Observation Log (179KB PDF)

SPA025 Assistant in Speech-Language Pathology Clinical Deficiency Plan Direct Supervision Log (160KB PDF)

Supervision Forms for Assistant in Speech-Language Pathology

SPA013 Speech-Language Pathology Supervisory Responsibility Statement (SRS) (81KB PDF)

SPA028 Speech-Language Pathology Alternate Supervision Plan revised October 2016 (87KB PDF)

SPA029 Supervision Log for the Licensed Assistant in Speech-Language Pathology (41KB PDF)

Other Forms

SPA026 Speech-Language Pathology and Audiology Notice of Change and Duplicate License Request (78KB PDF)

SPA027 Speech-Language Pathology and Audiology License Verification Form (50KB PDF)

TDLR Complaint Sign (19KB PDF)

Disciplinary Action Questionnaire (98KB PDF)

Criminal History Questionnaire (63KB PDF)

Military Service Member, Military Veteran, or Military Spouse Supplemental Application (110KB PDF) - see Military Spouse Frequently Asked Questions

Request to Executive Director for Expired License Renewal (56KB PDF)

Criminal History Evaluation Letter