State Board of Examiners for Speech-Language Pathology and Audiology Application & Forms

Application for Full Licensure Speech/Audiology

• Application Form (Word format, 126 KB)
• Application Form (Adobe Acrobat format, 73 KB)

Speech Assistant Licensure Forms 

• Application Form (Word format, 126 KB)
• Application Form (Adobe Acrobat format, 73 KB)
  
• Assistant License-Application Process (Word format, 32 KB)
• Assistant License-Application Process (Adobe Acrobat format, 19 KB)
  
• Clinical Observation and Experience for Assistants Form(Word format, 108 KB)
• Clinical Observation and Experience for Assistants Form( Adobe Acrobat format, 63 KB)
  
• Clinical Deficiency for Assistants Form (Word format, 79 KB)
• Clinical Deficiency for Assistants Form (Adobe Acrobat format, 106 KB) 
• Supervisory Responsibility for SLP - Assistants Form (Word format, 96 KB)
• Supervisory Responsibility for SLP - Assistants Form (Adobe Acrobat format, 53 KB)

Audiologist Application Form

• Application Form (Word format, 126 KB)
• Application Form (Adobe Acrobat format, 73 KB)

Speech Intern Licensure Forms

• Application Form (Word format, 126 KB)
• Application Form (Adobe Acrobat format, 73 KB)
  
• Intern License-Application Process (Word Format, 68 KB)
• Intern License-Application Process (Adobe Acrobat format, 39 KB)
  
• Intern Plan and Agreement of Supervision Form (Word format, 44 KB)
• Intern Plan and Agreement of Supervision Form (Adobe Acrobat format 98 KB)
  
• Speech-Language Pathology and Audiology Coursework and Clinical Experience Form (Word format, 65 KB)
• Speech-Language Pathology and Audiology Coursework and Clinical Experience Form (Adobe Acrobat format, 70 KB)
  
• Report of Completed Internship Form (Word format, 44 KB)
• Report of Completed Internship Form(Adobe Acrobat format, 28 KB)

Audiology Intern Forms

• Application Form (Word format, 126 KB)
• Application Form (Adobe Acrobat format, 73 KB)
  
• Audiology Intern Plan and Agreement of Supervision Form (Word format, 39 KB)
• Audiology Intern Plan and Agreement of Supervision Form (Adobe Acrobat format, 89 KB)
  
• Coursework and Clinical Experience Form for Audiology Intern (Word format, 60 KB)
• Coursework and Clinical Experience Form for Audiology Intern (Adobe Acrobat format, 56 KB)
  
• Report of Completed Audiology Internship Form (Word format, 33 KB)
• Report of Completed Audiology Internship Form (Adobe Acrobat format, 83 KB)

Exception Request to Supervise Forms

• Exception Request to Supervise With Less Than Three Years Experience Form (Word format, 57 KB)
• Exception Request to Supervise With Less Than Three Years Experience Form (Adobe Acrobat format, 50 KB)

• Exception Request to Supervise More Than Four Interns and/or Assistants Form (Word format, 57 KB)
• Exception Request to Supervise More Than Four Interns and/or Assistants Form (Adobe Acrobat format, 50 KB)

Alternate Supervision of an Assistant Request Plan

• Alternate Supervision of an Assistant Request Plan Form (Word format, KB)
• Alternate Supervision of an Assistant Request Plan Form (Adobe Acrobat format, KB)

Miscellaneous Forms and Information

• Name Change Form(Word format, 62 KB)
• Name Change Form(Adobe Acrobat format, 35 KB)

• Renewal/Late Renewal Form (Word format, 72 KB)
• Renewal/Late Renewal Form (Adobe Acrobat format, 43 KB)

• Felony/Misdemeanor Evaluation Form(Word format, 66 KB)
• Felony/Misdemeanor Evaluation Form(Adobe Acrobat format, 37 KB)

License Verification Form

• Word format, 63 KB
• Adobe Acrobat format, 34 KB

Duplicate License or Certificate Form

• Word format, 62 KB
• Adobe Acrobat format, 33 KB

Consumer Complaints Placard 

• Word format, 24 KB
• Adobe Acrobat format, 12 KB

To access documents in Adobe Acrobat format, you must download the Acrobat Reader software. Please see the DSHS file viewing page for more information and a link to the Adobe website.