New Mexico Regulation and Licensing Department
BOARDS AND COMMISSIONS DIVISION
New Mexico Speech-Language Pathology, Audiology and
Hearing Aid Dispensing Practices Board
T on ey An a ya Bu i ld in g ▪ PO Box 251 01 ▪ Sa nt a Fe, N ew Mexi co 87505
( 505) 476 -4640 ▪ Fax (505) 476 -4620 ▪ www.r ld .st at e.nm.u s
APPRENTICE IN SPEECH LANGUAGE PATHOLOGY (ASL)
2015 ANNUAL RENEWAL
Name
Address
City, State, Zip
License #
Initial License Date:
NOTE: ALL RENEWALS MUST BE COMPLETED AND POSTMARKED NO LATER THAN
August 30 OR A $75.00 LATE PENALTY FEE WILL BE ASSESSED. NO EXCEPTIONS!!!!
In order to renew your Temporary Paraprofessional Apprentice License in Speech Language Pathology (ASL)
and Pursuant to the Rules and Regulations you must meet the following requirements:
IF YOU HAVE BEEN LICENSED 2 OR MORE YEARS AND HAVE PROVIDED
DOCUMENTATION OF ACCEPTANCE INTO A MASTER’S DEGREE
PROGAM PLEASE SUBMIT THE FOLLOWING DOCUMENTATION: (A
temporary paraprofessional license may not be renewed if the licensee has not been accepted into a Master’s Degree program within
two years of initial licensure.)
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$50.00 Renewal Fee
Verification of Employment Form
Verification of Education Form
Course work completed in Communicative Disorders or other courses as outlined in the
degree plan with minimum GPA of 3.0
 Current Degree Plan
 Copy of transcripts from college or university
Temporary paraprofessional licenses as an apprentice in speech-language is a terminal license and as such may be renewed no more
than five times total.
IF YOU HAVE BEEN LICENSED FOR LESS THAN 2 YEARS, AND HAVE NOT BEEN ACCEPTED
INTO A MASTER'S DEGREE PROGRAM, SUBMIT EVIDENCE OF THE FOLLOWING:

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$50.00 Renewal Fee
Verification Employment Form
Verification of Education Form
Transcript indicating enrollment and completion of nine semester hours of graduate courses
with at least three hours in Communication Disorders. (Six may be in a related field.)
CONTINUED ON BACK
Revision date: 07/2010
New Mexico Speech -Language Pathology, Audiology and
Hearing Aid Dispensing Practices Board
ASL Renewal
Please read and answer the following questions:
1.
Are you in arrears in court-ordered child support in New Mexico?
____Yes
____No
2.
Have you been convicted of a felony in the past 2 years?
____Yes
____No
3.
Have you had any disciplinary action taken against you in any
state?
____Yes
____No
Applicant’s Signature___________________________________________________ Date___________
(Signature must be notarized)
State of _________________________________________ County of_____________________________
Before me on this day personally appeared the above named applicant who being by me duly
sworn upon oath says that all the acts, statements and answers contained in this application
are true and correct.
Sworn and subscribed to before me____________________________ on this _______ day
of_____,20_____
____________________________________
Notary Public
SEAL
My Commission Expires:______________
New Mexico Regulation and Licensing Department
BOARDS AND COMMISSION DIVISION
Page 2 of 5
Revision date: 03/2008
New Mexico Speech -Language Pathology, Audiology and
Hearing Aid Dispensing Practices Board
ASL Renewal
VERIFICATION OF EMPLOYMENT AND SUPERVISION
FOR TEMPORARY PARAPROFESSIONAL LICENSE
AS AN APPRENTICE IN SPEECH-LANGUAGE (ASL)
PART I - EMPLOYMENT AND SUPERVISION
Name of Employer (school district or business): ______________________________________________
Address: _____________________________________________________________________________
City: _______________________ State: __________________ Zip: _________ Phone: ______________
Name of Worksite Assignment (if other than above): __________________________________________
Name of Speech-Language Pathology Supervisor: ____________________________________________
Beginning Date of Supervision: _________________ Ending Date of Supervision: __________________
I hereby certify that I am the SLP supervisor assigned to the applicant listed above and that I will be
supervising this individual at all assigned worksites. My total supervision will be completed as follows:

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A minimum of 10% of contact time must be under direct supervision.
A minimum of 10% of indirect contact time must be monitored.
I acknowledge that I am aware I am legally responsible for the caseload assigned to the ASL.
Supervisor’s Signature: _________________________________________ License # ______________
PART II - TO BE COMPLETED BY APPLICANT’S CURRENT EMPLOYER
Name of Applicant: ______________________________________________ Date: _________________
Address: ____________________________ City: _______________ State: __________ Zip: _________
This is to verify that _________________________________________ is an employee in good standing.
(Employee name)
I confirm that the above named employee will engage in the following performance responsibilities.
Check all that apply.
 Screen speech-language and/or hearing abilities;
 Conduct treatment programs and procedures that are planned, selected and/or designed by the
Supervising Speech-Language Pathologist;
 Prepare written daily plans based on the overall intervention plan designed by the Supervising SpeechLanguage Pathologist;
 Record, chart, graph or otherwise display data relative to the client performance and report changes in
performance to the supervising SLP;
 Maintain daily service delivery/treatment notes and complete daily charges as requested;
 Assist the Speech-Language Pathologist during assessment of clients, such as those who are
difficult to test;
 Perform clerical duties (including maintenance of therapy/diagnostic materials, client files) as directed
by the supervising SLP
New Mexico Regulation and Licensing Department
BOARDS AND COMMISSION DIVISION
Page 3 of 5
Revision date: 03/2008
New Mexico Speech -Language Pathology, Audiology and
Hearing Aid Dispensing Practices Board
ASL Renewal
 Participate with the Speech-Language Pathologist in research projects, in-service training, and public
relations programs.
VERIFICATION OF EMPLOYMENT AND SUPERVISION continued
I confirm that the above named employee shall NOT engage in the following:
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Administer diagnostic tests
Interpret data into diagnostic statements or clinical management strategies or procedures
Select or discharge cases
Treat clients without following the individualized treatment plan
Interpret clinical information including data or impressions relative to client performance
Independent composition of clinical reports except for progress notes to be held in the client’s file
Refer clients to other professionals or agencies
Provide client or family counseling
Develop or modify client's IEP/IFSP Clinical Report or Plan of Care in any way without the
approval of the supervising SLP
Disclose clinical or confidential information
Sign any formal documents without the supervising SLP’s signature
I confirm that provision for supervision will be provided for the above named employee. Furthermore, the
supervisor will meet the following minimal requirements:
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At least two years of experience working as a Speech-Language Pathologist
Hold a New Mexico occupational license as a Speech-Language Pathologist
Provide a minimum of 10% direct and 10% indirect contact time with the above named employee
The supervising Speech-Language Pathologist will be given a copy of this form.
I recognize that it is the employer’s responsibility to be sure that the supervising SLP is provided a work
schedule that will allow for the necessary supervision of the employee listed above.
School District or Business:
__________________________________________________________
PART III - SIGNATURES
Signature of Supervisor:
Title:
Date:
Signature of Employer:
Title:
Date:
Signature of Applicant:
Title:
Date:
New Mexico Regulation and Licensing Department
BOARDS AND COMMISSION DIVISION
Page 4 of 5
Revision date: 03/2008
New Mexico Speech -Language Pathology, Audiology and
Hearing Aid Dispensing Practices Board
ASL Renewal
VERIFICATION OF EDUCATION
FOR TEMPORARY PARAPROFESSIONAL LICENSE
AS AN APPRENTICE IN SPEECH-LANGUAGE
To be completed by program director in the college in which the applicant is currently enrolled.
Name of Applicant: ________________________________________ Date: ________________
Address: ______________________________________________________________________
City: ________________________ State: _____________ Zip: _________ Phone:
I _____________________________ am requesting the release of the following information:
Applicant Name
Check one of the following:
 Enrolled in a Master’s Degree program in Speech-Language Pathology or Communication Disorders
and completes a minimum of 9 semester hours per year of graduate courses in Communication Disorders.
(Specify university and attach copy of degree plan)
OR
 Enrolled in and completes 9 semester hours of graduate courses per year with at least 3 hours in
Communication Disorders, 6 hours may be taken in a related field.
(Specify university)
Indicate dates nine (9) hours of coursework will be or have been completed:
Has applicant met the GPA requirement of 3.0?
 Yes  No
Acceptance into a Master’s Degree program must take place within two years of initial license.
Program Director’s Name (Print)
Program Director’s Signature
Date
New Mexico Regulation and Licensing Department
BOARDS AND COMMISSION DIVISION
Page 5 of 5
Revision date: 03/2008