Please complete and
print the following form. Membership
is $125 per calendar year. Send your completed form, along
with a cheque made payable
to ASAPP, to: ASAPP Membership, 6716 - 33 Avenue,
Edmonton, AB T6K 1L4. * * To be included
on the 2012 Private Practice Roster that will be mailed to
all employing agencies,
please ensure that your application form and payment are received
by January 16, 2012.
Yes, I graduated in
and have a minimum of 3 years clinical experience.
ACSLPA Registration #:
Yes, I hold Policy #:
representing my own current liability insurance.
First Name:
Last Name:
Company Name:
City:
Address:
Area:
Postal code:
Please check if you would like to list your address rather than your area on
the
website.
Phone:
Fax:
Email:
Time Basis of Practice:
Are you Currently Taking New Clients?
Area of Clinical
Concentration (in 40 words or less, list your areas of clinical
concentration such as disorders, age groups,etc.)
Services are offered in language(s) other than English: (list languages)
As an organization
of fellow speech-language pathologists seeing clients
privately, ASAPP strongly recommends that you:
·
comply with ASAPP’s definition
of a Private Practitioner in that you are an individual
clinician
in private practice,
are self-employed, are the owner / co-owner of the practice
or officer of an incorporated company, are registered with
ACSLPA, and have a minimum of 3 years experience
At a recent ASAPP Board meeting, it was agreed that our
website could have better search fields:
Practitioner Last Name
Practitioner Location (could be city or area)
Age Group
Clinical Services
For example, browsers can search “Edmonton” and “Preschool
(0-4)” and “Autism Spectrum Disorder” to
view a more precise list of private SLPs that match those
criteria.
Currently the search is by Area (formerly Region),
City, or Lastname which requires browsers to read through
many
members’ service information before contacting
private SLPs for help.
Below are descriptive terms that may apply to your
private practice regarding the location(s), age group(s),
and
clinical services you provide. This information will
be recorded in our database. Your current “Concentration” (description
of services) as written on the opposite page will continue.
LOCATIONS
I only service my city / town of residence.
OR list the cities / towns below that you service which
are beyond your
city / town of residence:
1.
2.
3.
4.
5.
6.
7.
8.
PLEASE CHECK ALL THAT APPLY:
AGE GROUP
Preschool (0-4)
School Age (5 – 17)
Adult (18 – 64)
Seniors (65+)
CLINICAL SERVICES
Articulation / Phonology
Accent Reduction
Augmentative / Alternative Communication Technology
Aural Rehabilitation
Autism Spectrum Disorder
(Central) Auditory Processing
Children with complex Physical Needs
Brain Injury / Cognitive Communication Disorders
Communication Improvements (eg. public speaking)
Deaf / Hearing Impaired
Dementia (eg. Alzheimer’s)
Developmental Disabilities (eg. Down Syndrome, Mild
intellectual delay)
Head and Neck Cancer
(eg. Laryngectomy)
Language Delay
Learning Disabilities
(eg. Dyslexia, ADHD, LLD)
Literacy (eg. reading and writing)
Oral Motor Speech Delay / Disorder
(eg. apraxia, dysarthria)
Pervasive Developmental Disorder
Progressive Neurological Disease
(eg. Parkinson’s, ALS, MS)
Resonance (eg. cleft lip / palate)
Selective Mutism
Stroke (eg. aphasia, dysarthria, apraxia)
Stuttering (fluency)
Swallowing Disorders / Dysphagia
Tongue Thrust / Myofunctional Therapy
Voice Disorders
(eg. nodules, polyps, hoarsness, cysts
