Customer
Qualification Form
The
Neuropsychology Center provides Halstead-Reitan Neuropsychological Battery
equipment and materials for use in neuropsychological practice, training, and
research. These materials are to be used
in accordance with APA Ethical Principles and the Standards for Educational and
Psychological Testing.
Please
print and complete this qualification form, if this is your first
order with The Neuropsychology Center. Fax, mail or email the completed
form to:
The
9400 N Central
Expressway,
Fax: 214-373-0762
Email: HRB@neuropsych.com
Name:
________________________________________________________________________________
Address:
______________________________________________________________________________
City/State/Zip:
__________________________________________________________________________
Telephone:
(_____)____________ Fax: (_____)____________ Email:
_____________________________
License to practice
psychology:
License #: _____________
State: __________ Expiration date: ____________________
è Attach a copy of your
license and proceed to the signature section, below.
If not a licensed psychologist, please complete the
questions below:
Are you a member of
APA? __ yes __ no If
yes, please provide your membership #: ____________
Educational
Background:
College
or University (highest degree): ______________________________________________________
Degree/Year: _____________________________Major
Field:
__________________________________
To
what purpose will the testing materials be used? ___________________________________________
_____________________________________________________________________________________
Signature:
I certify that the above information is complete and
accurate, and that all materials purchased from The
Signature:
_______________________________________________ Date:
_______________________
Name
(printed):
________________________________________________________________________
Graduate students
must include the information/signature of a faculty advisor who assumes
responsibility for the use of the test materials.