S.T.E.P. Mentor Enrollment Form

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

* Indicates a required field

ASHA/ NSSLHA Member ID:*
 
First Name:*
 
Last Name:*
 
Home Telephone Number:*
 
Cell Phone Number:
Would you accept text messages?
Email Address:*
 

In which state do you currently reside?*
 

What is your area of practice?* (Select all that apply.)
Audiology
Speech-Language Pathology
Speech, Language and Hearing Science
 
Please indicate your highest degree.*
 
How many years of experience do you have in the profession(s)?*
 

What clinical age population(s) do you work with?* (Select all that apply.)
Infants
Children
Adults
 
What is your primary employment function?*
 
Which employment facility best describes where you work most of the time?*
 
The following is a list of specialty areas. Please choose your top 3 specialty areas.*
Which best describes your 1st area of expertise?
 
Which best describes your 2nd area of expertise?
 
Which best describes your 3rd area of expertise?
 
  • Accent modification

  • Administration/planning for continuing education programs

  • Articulation/phonological disorders

  • Assistive listening devices

  • Augmentative/alternative communication

  • Aural (re)habilitation

  • Autism

  • Balance assessment/treatment
  • Central auditory processing

  • Cerumen management

  • Cochlear implants

  • Cognitive-communication disorders

  • Communication improvement (professional speaking)

  • Consumer advocacy

  • Educational Audiology

  • Electrocochleography
  • Electrophysiological measures

  • Evoked potential testing

  • Fluency and fluency disorders

  • Forensic audiology

  • Government and social policy

  • Graduate personnel preparation

  • Hearing aid evaluation

  • Hearing aid/product dispensing
  • Intraoperative monitoring

  • Language acquisition/disorders

  • Laryngectomy

  • Learning disabilities

  • Managed care

  • Marketing

  • Multicultural aspects of practice

  • Multilingualism

  • Neurogenic communication disorders
  • Newborn hearing screening

  • Occupational hearing conservation

  • Orofacial myofunctional disorders

  • Otoacoustic emissions

  • Pediatric assessment

  • Phonology and phonological disorders

  • Quality assurance

  • Reimbursement
  • SLP developmental disabilities

  • Structurally based speech disorders

  • Swallowing disorders

  • Tinnitus

  • Treatment outcomes and efficacy measures

  • Voice disorders

  • Wellness programs

In addition to English, I speak fluent:

If you work at a college/university, do you mind if you are matched with a student from your university program?

How did you hear about this program?*
 
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.)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
 

Print This Page