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Speech Language Pathologists and Audiologists Forms

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Speech-Language Pathologists

Title Document Number
Speech-Language Pathology Application (including ASHA Waiver) (PDF) SPA006

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

Title Document Number
Upgrade Intern in Speech-Language Pathologist Application (PDF) SPA010
Speech-Language Pathology Report of Completed Internship Form (PDF) SPA015

Intern in Speech-Language Pathology

Title Document Number
Intern In Speech-Language Pathology Application (PDF) SPA008
Speech-Language Pathology Intern Plan and Agreement of Supervision (PDF) SPA-LIC-012-E
Intern in Speech-Language Pathology Course Work and Clinical Experience Form (PDF) SPA-LIC-016-E
Evaluation of Internship and Intern Plan of Agreement and Supervision in Speech-Language Pathology (PDF) SPA-LIC-031-E

Assistant in Speech-Language Pathology

Title Document Number
Assistant in Speech-Language Pathology Application (PDF) SPA007
Speech-Language Pathology Supervisory Responsibility Statement (SRS) (PDF) SPA013
Clinical Observation and Experience Form for Speech-Language Pathology Assistant (PDF) SPA-LIC-017-E
Assistant in Speech-Language Pathology Clinical Deficiency Plan (PDF) SPA021

Supervision Forms for Assistant in Speech-Language Pathology

Title Document Number
Speech-Language Pathology Supervisory Responsibility Statement (SRS) (PDF) SPA013
Supervision Log for the Licensed Assistant in Speech-Language Pathology (PDF) SPA-LIC-029-E

Clinical Deficiency Plan for Assistant in Speech-Language Pathology

Title Document Number
Assistant in Speech-Language Pathology Clinical Deficiency Plan (PDF) SPA021
Assistant in speech-language Pathology Clinical Deficiency Plan Completion of Training and Rating Scale (PDF) SPA-LIC-023-E
Assistant in Speech-Language Pathology Clinical Deficiency Plan Observation Log (PDF) SPA024
Assistant in Speech-Language Pathology Clinical Deficiency Plan Direct Supervision Log (PDF) SPA025

Audiologists

Title Document Number
Audiology Application (including ASHA or ABA Waiver) (PDF) SPA005
Audiology Intern Plan and Agreement of Supervision (PDF) SPA014
Intern in Audiology Course Work and Clinical Experience Form (PDF) SPA-LIC-020-E

Intern in Audiology

Title Document Number
Intern In Audiology Application (PDF) SPA002
Audiology Intern Plan and Agreement of Supervision (PDF) SPA014
Report of Completed in Internship in Audiology Form (PDF) SPA-LIC-019-E
Intern in Audiology Course Work and Clinical Experience Form (PDF) SPA-LIC-020-E
Evaluation of Internship and Intern Plan of Agreement and Supervision in Audiology (PDF) SPA-LIC-030-E

Intern in Audiology Upgrade to Audiologist

Title Document Number
Upgrade Intern Audiologist Application (PDF) SPA004
Report of Completed in Internship in Audiology Form (PDF) SPA-LIC-019-E

Assistant in Audiology

Title Document Number
Assistant In Audiology Application (PDF) SPA-LIC-001-E
Report of Completed Training for an Assistant in Audiology (PDF) SPA011
Assistant in Audiology Supervisory Responsibility Statement (SRS) (PDF) SPA-LIC-018-E

Other Forms

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

SPA-LIC-027-E Speech-Language Pathology and Audiology License Verification Form (PDF)

Occupational License Application Claiming to Have No Social Security Number

TDLR Complaint Sign (PDF)

Disciplinary Action Questionnaire (PDF)

Criminal History Questionnaire (PDF)

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

Request to Executive Director for Expired License Renewal (PDF)

Criminal History Evaluation Letter

Expert Witness Application