Empowered Voice Rehabilitation SLP Graduate Student Application

Empowered Voice Rehabilitation SLP Graduate Student Clinician Application

Fill the form below as accurately as possible.
Name:*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number:*

Area CodePhone Number
E-mail Address:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload Cover Letter:

Upload a File

Cancelof
Upload Resume:*

Upload a File

Cancelof
Upload BLS Certification:*

Upload a File

Cancelof
Upload Deidentified Treatment Note Sample:*

Upload a File

Cancelof
Upload Deidentified Evaluation Note Sample:*

Upload a File

Cancelof
Education
Undergraduate*
Graduate*
Skills & Training
Training or Certifications:
Practicum
Why are you applying for this clinical practicum?*

Rank your comfort level with evaluation in the following clinical areas of speech-language pathology. *

	Independent	Needs minimal support	Needs moderate support	Needs maximum support	No experience
Aphasia
Cognitive-Linguistic Disorders
Motor Speech Disorders
Dysphagia
Voice & Upper Airway Disorders
Augmentative & alternative communication
FEES
Videostroboscopy

Rank your comfort level with treatment in the following clinical areas of speech-language pathology. *

	Independent	Needs minimal support	Needs moderate support	Needs maximum support	No experience
Aphasia
Cognitive-Linguistic Disorders
Motor Speech Disorders
Dysphagia
Voice & Upper Airway Disorders
Augmentative & alternative communication

Practicum Availability
Anticipated start date for practicum*

MonthDayYear
Date
Anticipated end date for practicum*

MonthDayYear
Date
Please select your availability for this practicum.*
List any dates that you know you will be unavailable during this practicum period:
Problem Solving Scenarios

Please answer the following questions.
Explain the steps you would take to complete a clinical "bedside" swallow evaluation from start to finish. *
You are conducting a LOUD Crowd® group maintenance session for patients with Parkinson's disease. Provide one example of a cognitive-linguistic task that you could utilize during this group session. Tell me how you would modify this task for a patient who has a mild cognitive-linguistic impairment and how you would modify the same task for a patient who has a severe cognitive-linguistic impairment. *
Information provided by your supervisor conflicts with information presented in one of your classes. How do you address this situation? *
Professional References

Please list two (2) references that are familiar with your work life and/or school work.
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Years Known:*
Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Years Known:*
Signature*

Clear
Should be Empty: