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 Neuropsychology Center

9400 N Central Expressway, Ste 904

Dallas, TX  75231-5049

Fax: 214-373-0762

Email: HRB@neuropsych.com

Name: ________________________________________________________________________________

Address: ______________________________________________________________________________

City/State/Zip: __________________________________________________________________________

Telephone: (_____)____________ Fax: (_____)____________ Email: _____________________________

License to practice psychology:

License #:  _____________                    State: __________         Expiration date: ____________________

Attach a copy of your license and proceed to the SIGNATURE section, below, OR if not a licensed psychologist, please complete the following questions:

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 Neuropsychology Center will be used in accordance with APA Ethical Principles and the Standards for Educational and Psychological Testing.

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.