Customer Qualification Policy & Form – The Neuropsychology Center

QUALIFICATION POLICY & FORM

The Neuropsychology Center provides Halstead-Reitan Battery (HRB) testing equipment and materials for use in neuropsychological practice, training, and research. These materials are to be used in accordance with APA Ethical Principles (2002) and the Standards for Educational and Psychological Testing (AERA, APA, NCME, 1999). Purchasers are expected to use the test materials in a manner consistent with these standards.

Customer Qualification Policy
There are two levels of qualifications for use of HRB test materials and equipment. HRB test materials and equipment are restricted for use by neuropsychologists and other qualified psychologists. These materials can appropriately be used by individuals who are not necessarily psychologists but who have specialized training, education, or experience with test procedures. These two levels are described below:

Level A: Individuals who are practicing neuropsychologists or are licensed psychologists with training in neuropsychology. These users must provide documentation of their state license or appropriate certification in their jurisdiction for the independent practice of psychology.
Level B: Individuals with specialized training, graduate education, and/or experience in psychological and neuropsychological testing. These users must provide information regarding their qualifications in these areas and their training in test and measurement theory and methods.

Terms and conditions
By registering as a new user or ordering materials, the purchaser agrees to the Terms of Use, Customer Qualifications, Ordering & Shipping Policy, and Privacy Policy.

NEW CUSTOMER
QUALIFICATION FORM

To be able to purchase HRB Materials, fill out this qualification form with your order.

If you prefer to submit the form via email or mail, download this form

First Name*

Last Name*

Address*

Town/City*

State/Province*

Zipcode/Postal Code

Country*

Phone Number*

E-mail Address*

Are you a licensed psychologist?*

YesNo

LICENSE TO PRACTICE PSYCHOLOGY:

License State*

License Number*

License expiration date*

License File Upload (Required for non-US applicants)

Upload License

Are you a member of APA?*

YesNo

APA Membership number*

EDUCATIONAL BACKGROUND

College or University (highest degree)*

Degree*

Degree Year*

Major Field*

Graduate student, post doctoral fellow or individuals working under supervision?

YesNo

Please have your faculty advisor/supervisor submit a Customer Qualification Form to assume responsibility for the use of the test materials.

Faculty Advisor/Supervisor Name

Faculty Advisor/Supervisor Contact Information

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.

Only fill in if you are not human

QUALIFICATION POLICY & FORM

NEW CUSTOMER QUALIFICATION FORM

To be able to purchase HRB Materials, fill out this qualification form with your order.

LICENSE TO PRACTICE PSYCHOLOGY:

EDUCATIONAL BACKGROUND

NEW CUSTOMER
QUALIFICATION FORM