CURRENT MEMBERS DO NOT USE THIS!  UPDATE YOUR PROFILE HERE.  

NEW MEMBER APPLICATION

NEW MEMBER ONLY APPLICATION

Thank  you for your interest in becoming a member!  Please submit your payment of $185 USD below for your application fee ($35) and your first year membership ($150).  If approved, your annual membership fee will be reduced to $150.  If you are denied, your $150 will be refunded.  The $35 application fee is non-refundable.  Once you submit payment AND get your paypal receipt, please fill in the form below and submit. 

CHECK YOUR STATUS

Enter your email here to check the status of  your application or renewal

Status message

arrow&v
arrow&v

Member Information (Form 1 of 2)

Full Name

Home Address

Credentials

Business Name

Business Address

City (Business)

State (Business)

Postal code  (Business)

Country (Business)

Email

Cell Phone

Home Phone

Business Phone

Business Fax

URL

Preferred Mailing Address

Add to Listserv?

Where do you visit clients?

Office

Hospital/Clinic

Your Home

Their Home

Other

Business Description/Specialty

Practice Information (Form 2 of 2)

Accept Referrals?

Full Name as ASHA Member

ASHA ID

Professional Affiliations

Number Employees

Publications

Licenses

Payment Method and Name

How did you hear about us?

If Multi-Disciplinary, Explain

What Types of Patients do you see?

Do You have Complaints Against You?

Speech or Audiology License?

State Licensed In

State License Number

License Expiration Date

Twitter

Facebook

LinkedIn

Secondary Business Address

Business Structure

Billable Hrs./Week

# Days seeing Clients per week

Describe Business Structure

Please Explain Other Places if Other is Checked

If Other Please Explain

Please explain complaints

Have you ever been disciplined?

Mandatory Information (3 of 3)

Please answer all questions in the section.   Any questions not answered in this section will result in a denied application.

How many clients are billed for at  your private practice weekly? 

If your practice is not currently billing for any clients, are you an AAPPSPA Life Member or a Past President?

No

Yes

Are you the owner or the co-owner of this private practice?

No

Yes

If you are not the owner or co-owner, please explain.

Do you have ethical, professional and administrative responsibility for this practice?

No

Yes

If no, please explain

Do you have financial and legal responsibility for this practice?

No

Yes

If no, please explain

Are you responsible for obtaining new referrals/clients for your practice?

No

Yes

If no, please explain

For which types of services do you typically bill: please mark all that apply

If  you checked other please explain

Do you hold the Certificate of Clinical Competence from ASHA (CCC)?

No

Yes

If no, please explain

Have you complied with the rules set forth in the Code of Professional Ethics of the American Speech-Language-Hearing Association? 

No

Yes

If no, please explain

Ever Convicted of a Felony?

No

Yes

Please Explain Felony Conviction

I certify that the information I have provided here is true and accurate to the best of my knowledge.

I personally submitted this information and did not submit this on someone else's behalf.

DID YOU FILL OUT ALL REQUIRED FIELDS?

Please note, you will not be able to log into our member's only sections nor will you be added to our listserv or mailing lists until your application is fully approved by AAPPSPA.  This can take 2-3 weeks.   Please contact office@aappspa.org if you have any questions about this.

AAPPSPA SPONSORS
1/19
ADDRESS

AAPPSPA 
PO Box 252 
Granville, NY 12832

General Inquiries: office@aappspa.org

CONTACT US
  • Grey Facebook Icon
  • Grey Twitter Icon

© 2019 by AAPPSPA. See more creations like this from VirtuOps