Qualification Form The SASSI Institute's products are carefully developed assessment instruments that require proper administration, scoring, and interpretation. In accordance with the ethical guidelines of the American Psychological Association, a completed Qualification Form must be received prior to initial purchase. Eligibility to purchase, administer and/or use these measures for clinical purposes is limited to individuals with training and experience in the area of assessment. Individuals who do not have professional training can administer and score the instrument if there is appropriate supervision. If you are unable to check one of the professional qualifications below or have not attended a SASSI Training, please have your supervisor complete and submit. For questions related to qualifying, call 800.726.0526. Upon submission of the electronic qualification form, you will receive an invitation to be added to our Electronic Newsletter. If you wish to not be added to the list, simply delete and ignore the message Name* First Last Email* Enter Email Confirm Email Phone*FaxCompany Name*Company Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Company Phone NumberProfessional Qualfication* Lic./Cert. Psychologist Psychiatrist or other MD Licensed Psychiatric Nurse Lic./Cert. Addictions Counselor (e.g., CADC, LCDC) Lic./Cert. Counselor/Therapist (e.g., LMFT, LPC) Lic./Cert. Social Worker Lic./Cert. Rehabilitation Counselor (e.g., CRC, Rh.D.) Research Ph.D / Clinical Ph.D IC&RC (e.g., AODA, CCJP, CCDP) Training Other License or Certificate Non-licensed or certified (fill out additional information) Location of Training*Please provide the location your training workshop was conducted.SASSI Certified Trainer's Name*Please provide the name of the SASSI certified trainer that conducted your training.Training Date*Please provide the month and year you completed SASSI training.Specify Other License or Certificate*Please provide what other license or certificate you have that is not covered in the list.Additional Information*Please provide additional information about your training and/or experience in the area of assessment. eg: Degree (include University, Major, year of completion), or Relevant Professional Experience (include Organization, Assessment Tools Used and dates of employment).Work Setting*Please mark the items which best describe your current work setting (check all that apply). EAP, Union, DOT-SAP Probation, Parole, Pre-sentencing Drug Court Workforce Development Jail, Prison Behavioral Health Facility Secondary / College Education Welfare, Child Protective Services Medical, Hospital, HMO Military Vocational Rehabilitation Substance Abuse Treatment Program Private Practice Other Other Work Setting*Please specify the type of work setting.How did you hear about The SASSI Institute?*Please check all that apply. SASSI Information Packet Internet Advertisement Required Use SASSI Newsletter Word of Mouth Used before in another position Current setting uses SASSI Current setting uses BADDS SASSI Training Other Other referral source?*Please specify how you hear about us. e.g. Published Articles, Journal Ads, Conferences (please include conference name and date), or any other sources.Certification*Purchaser agrees to indemnify and hold The SASSI Institute and its owners, officers, directors, employees, independent contractors, suppliers, and affiliated parties harmless against all claims, liabilities, demands, damages, judgments, settlements, or expenses of whatever nature (including reasonable attorneys' fees and expenses) arising out of or in connection with the use or misuse of materials, scoring, or other services connected to administration of substance use measures created by and/or distributed by The SASSI Institute. I certify that I have read and agree to the above terms and conditions. Signature*Type your first and last name as your signature.