Long Island Speech-Language-Hearing Association

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Professionals / Referral Form

If you are a licensed Speech-Language Pathologist or Audiologist, Hospital, Clinic, University or other approved agency and would like to be listed on our web site referral list, please complete the form below.

YOU MUST BE A CURRENT MEMBER OF LISHA!

All items in BOLD must be completed for inclusion in the list.

Name:
Title:
	SLP: Aud:
Worksite:
Address:
City:	State:
Zip:	County:
Phone:	Fax:
E-Mail:
N.Y. State License#	AUD SLP
Population Served:	Infant:	Preschool:
	School Age:	Adult:
	Geriatric:	All:

Treatment Preferences (Select ONLY 4)
Speech/Language
Accent Reduction		All
Aphasia		Apraxia/dysarthria
Articulation/phonology		Augmentative communication
Autism/ABA		Central auditory processing
Cochlear implants		Developmental Disabilities (MR)
Dysphagia/feeding		Head Injury/TBI
Language Disorders		Laryngectomy/Glossectomy
Myofunctional/oral motor		Sign Language
Stuttering		Voice
Certified Prompt Therapist
Audiology
CAPD testing		FM amplification
Hearing Aids		Hearing evaluations

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Need more information?
Call: LISHA Hotline at (516) 626-8000 or (631) 395-2770
Email to info@LISHA.org
Write: LISHA, PO BOX 133, Mastic Beach, NY 11951-0133
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ALL LISHA MEMBERS:
There is NO ON-SITE REGISTRATION at any LISHA Event. All Participants must pre-register via workshop flyer procedures. No Refunds will be issued within 48 hours of each sponsored event. Please remember that WE ARE NOT ABLE TO ACCEPT PURCHASE ORDERS from SCHOOL DISTRICTS or CREDIT CARDS for ANY WORKSHOP PROGRAM OFFERED. Personal checks returned due to "INSUFFICIENT FUNDS" will incur a $35.00 processing fee in addition to any bank charges.

To insure the accuracy of our records, please notify us when you have a change of name, address and/or telephone number. Send updated information to our Registrar, Patricia Luft at lishapat@aol.com.