American Speech-Language-Hearing Association

S.T.E.P. Mentor Enrollment Form

Questions? Contact Andrea "Deedee" Moxley, Associate Director, Office of Multicultural Affairs, or Melanie Johnson, Membership Program Manager, at step@asha.org.

* indicates required field.

Contact Information

ASHA/NSSLHA Account Number:*

First Name:*

Last Name:*

Daytime Phone Number:*

Cell Phone Number:

E-mail:*

State:*

What is your gender?*

    

Which of the following best describes your ethnicity (select one)?*

    

Which of the following best describes your race (select all that apply)?*

    

In addition to English, I am fluent in:


Education/Work Experience

Area of Practice (select all that apply):*

    

Please indicate your highest degree.*

Years of Experience in the Profession(s)?*

Primary Clinical Population You Work With:*

Primary Employment Function:*

Primary Employment Facility:*

For AUDIOLOGISTS, the following is a list of specialty areas in the field of communication sciences and disorders. Please choose your top three areas of interest.*

Administration/Planning for Continuing Education Programs, Assistive Listening Devices, Aural (Re)Habilitation, Balance Assessment/Treatment, Central Auditory Processing, Cerumen Management, Cochlear Implants, Consumer Advocacy, Educational Audiology, Electrocochleography, Electrophysiological Measures, Evoked Potential Testing, Forensic Audiology, Government and Social Policy, Graduate Personnel Preparation, Hearing Aid Evaluation, Hearing Aid/Product Dispensing, Intraoperative Monitoring, Managed Care, Marketing, Multicultural Aspects of Practice, Multilingualism, Newborn Hearing Screening, Occupational Hearing Conservation, Otoacoustic Emissions, Quality Assurance, Reimbursement, Tinnitus, Treatment Outcomes and Efficacy Measures, Wellness Programs

For SPEECH-LANGUAGE PATHOLOGISTS, the following is a list of specialty areas in the field of communication sciences and disorders. Please choose your top three areas of interest.*

Accent Modification, Administration/Planning for Continuing Education Programs, Articulation/Phonological Disorders, Augmentative/Alternative Communication, Aural (Re)Habilitation, Autism, Central Auditory Processing, Cochlear Implants, Communication Improvement (Professional Speaking), Consumer Advocacy, Fluency and Fluency Disorders, Government and Social Policy, Graduate Personnel Preparation, Language Acquisition/Disorders, Laryngectomy, Learning Disabilities, Managed Care, Marketing, Multicultural Aspects of Practice, Multilingualism, Neurogenic Communication Disorders, Orofacial Myofunctional Disorders, Phonology and Phonological Disorders, Quality Assurance, Reimbursement, SLP Developmental Disabilities, Structurally Based Speech Disorders, Swallowing Disorders, Treatment Outcomes and Efficacy Measures, Voice Disorders, Wellness Programs

   

Provide a brief overview of your career.*

Please indicate your membership and/or affiliation in the following groups.

    

How did you hear about this program?*

What topics would you like to see for Monday Connection on the ASHA Community to assist in supporting your goals?*

    

Would you be willing to blog about your mentoring experience?

    

In response to feedback, the S.T.E.P. mentoring program will arrange monthly office hours for you to connect with fellow mentors and mentees.  Which format would you prefer to participate in?

    

Attestations

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