Embed Size (px)
Citation preview
2017 Product Catalog
We continue to focus our research and development initiatives on instruments that will assist professionals working with adults,
adolescents, Spanish-speaking, and other special populations.
We remain devoted
2018 Product Catalog
accurate objective informativeefficienteffectiveversatilevalidated
2
Contents333
4
55555566666
777
Qualifications & Guidelines Qualifications for Purchase Use Guidelines
Product Overviews
Paper & Pencil Pricing SASSI-4 SASSI-A2 Spanish SASSI BADDS Starter Kits Paper Sets Audio Recordings Scoring Keys User Guides & Manuals BADDS Auto-Calculation Sheets SASSI Online Features Pricing
Training Continuing Education Options Available Workshops
Scantron/Optical Scanning Paper with Automated Scoring and Screening Reports Overview Pricing SAS-ASL SAVR-S2
Return PolicyCopyright Information
U.S. Qualification FormU.S. Order Form
Canada Qualification FormCanada Order Form
Shipping Information
888
9
99999
1010
insertinsert
insertinsert
11
No-risk 30-day trial on
small starter kitssee page 10 for more details
ContactCustomer Service Ordering and general inquiries
Training Department Questions or assistance specific to training
Technical Support Software and online support
Clinical Support Free Clinical consultation
LocationWebsite
888.297.2774blank text for spaceing
201 Camelot Lane, Springville, IN 47462www.sassi.com
Drug Courts Employee Assistance Programs Spanish DUI Evaluation Medical Program EvaluationCollege
CANADAU.S. & Canada
3
Child Protective ServicesDepartment of Transportation Evaluations
The SASSI-4, SASSI-A2, Spanish SASSI, SAS-ASL and SAVR-S2 are carefully developed screening instruments that require proper administration, scoring, and interpretation. Therefore, 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 and should be used by:
Human service practitioners whose certifica-tion and/or professional training includes assess-ment (e.g., psychologists, social workers, certi-fied addictions counselors) or
Individuals who have completed SASSI training that was presented by a certified SASSI trainer.
Individuals who do not have professional training can administer and score the instruments if there is appropriate supervision.
It is suggested that you contact your state or provin-cial government for specific information on the laws regulating assessment and testing in your area.
Qualifications for SASSI Purchase
Use Guidelines
Product Pricing is in US & Canadian Funds
A bachelor’s degree in psychology or a related disci-pline (e.g. counseling, education, human resources, social work, criminal justice, etc.) and coursework related to psychological testing,
or
Professional membership in an organization that requires training and experience in the use of psycho-logical assessments and surveys,
or
Individuals who have completed BADDS training online.
Please note: If you do not meet the above criteria, but are supervised by someone who does, you may still use the BADDS. However, the Qualification Form must be completed by the qualifying individual.
We hereby advise the Purchaser of the following guidelines:
The SASSI instruments are designed and distribut-ed for use as screening instruments and, as such, do not yield diagnoses.
The SASSI instruments are also designed to identi-fy people with likely substance use disorders regardless of the current course of the disorder; thus, individuals who are in remission or recovery may show test-positive results.
The SASSI instruments and the BADDS should not be used as part of a screening process to discriminate against individuals, i.e., eliminate job applicants, abridge people’s rights and entitlements for general assistance or other aid, or for any other purpose that may violate the Americans With Disabilities Act, Human Rights laws or other state, province, or federal civil rights laws.
Refer to the SASSI instrument manuals, the BADDS User’s Guide/Manual, or contact us for information regarding development and valida-tion.
Initial orders require a completed Qualification Form. The ethical guidelines of the American Psychological Association require us to have this information at the time we fill your first order. For mail and fax orders, complete and return the Qualification Form included in this catalog with your order form.
You may also complete the Qualification Form online at www.sassi.com/qualify (online order-ing is available to U.S. residents only).
Qualifications for BADDS Purchase
First Time Orders
4
Product Overviews
Identifies high or low probability of substance use disorders and includes a prescription drug scale that identifies individuals likely to be abusing prescription medications. It also provides a measure of profile validity and clinical insight into level of defensiveness and willingness to acknowledge experienced consequences of substance use disorder.
SASSI-4 Adult Substance Abuse Subtle Screening Inventory-4
Formats Available: Paper & Pencil, SASSI Online, Scantron/Optical ScanningAge: 18 years and up Accuracy: 92% based on empirical studiesReading Grade Level: 4th - 5th
SASSI-A2 Adolescent Substance Abuse Subtle Screening Inventory-A2Identifies high or low probability of substance use disorders in clients. It also provides clinical insight into family and social risk factors, level of defensive responding, and consequences of substance misuse teens endorsed.
Formats Available: Paper & Pencil, SASSI Online, Scantron/Optical ScanningAge: 12-18 years Accuracy: 94% based on empirical studiesReading Grade Level: 4.4
Spanish SASSI Spanish Substance Abuse Subtle Screening InventoryA Spanish language screening instrument empirically validated in clinical settings for use with Spanish-speaking adults from diverse ethnic backgrounds (e.g., Colombian, Mexican, Puerto Rican).
Formats Available: Paper & Pencil, SASSI OnlineAge: 18 years and up Accuracy: 84% based on empirical studiesReading Grade Level: 5th
BADDS Behaviors & Attitudes Drinking & Driving ScaleIdentifies preintervention risk of future impaired driving, and changes in DUI-related risky behaviors & attitudes following intervention. Ideal for initial risk assessment, pre and post test screening, and program evaluation.
Age: 18 years and up Formats Available: Paper & PencilReading Grade Level: 3.1Validation Samples: DUI offenders, Traffic offenders with no history of DUI, Adults in treatment for substance use, College students, High School students in driver’s education
SAVR-S2 Substance Abuse in Vocational Rehabilitation Screener2A brief screener validated for use with clients with disabilities, to identify high or low probability of substance use disorders, including misuse of medications.
Formats Available: Scoring & Report ServiceAge: 18 years and up Accuracy: 86% based on empirical studiesReading Grade Level: 5th
SAS-ASL Substance Abuse Screener in American Sign LanguageAn instrument specifically developed in American Sign Language and validated to screen for substance use disorders among adult Deaf and Hard of Hearing clients in vocational rehabilitation, mental health, and social service settings.
Formats Available: Scoring & Report ServiceAge: 18 years and up Accuracy: 87% based on empirical studiesReading Grade Level: 4th
VeteransStudent Assistance Department of Transportation Evaluations Workforce Development ASL
5
Paper & Pencil PricingOverview: Counselor hand scores completed questionnaire using a scoring key. Results are immediately available. Fifteen minutes to administer & score. No-risk 30-day trial on small starter kits, see page 10 for more details.
Starter Kits First time orders for the paper & pencil product must be a Starter Kit.
Continued on next page
DUI Evaluations Welfare Drug Courts Jails Program Evaluations
Adult & Adolescent SASSI Starter Kit includes questionnaires and profiles, scoring key, User Guide/Manual. Small Kit - 25 questionnaires and profiles Large Kit - 100 questionnaires and profiles
Combination Adult and Adolescent Kit includes questionnaires and profiles, scoring keys, User Guide/Manuals. Small Kit - 25 Adult and 25 Adolescent Large Kit - 100 Adult and 100 Adolescent
Spanish Starter Kit includes questionnaires and profiles, scoring key, Administration & Scoring Instructions, Development & Validation Information, and an English translation of the questionnaire. Small Kit - 25 questionnaires and profiles Large Kit - 100 questionnaires and profiles
BADDS Pretest Starter Kit is designed for those using the BADDS as a pretest measure only. The kit includes questionnaires and profiles, Reliability & Validity information, and the User Guide/Manual. Small Kit - 25 questionnaires and profiles Large Kit - 100 questionnaires and profiles
BADDS Pre-Posttest Starter Kits are designed for those using the BADDS as a pre-post measure to assess intervention effectiveness. The kit includes questionnaires (2 per client), pre-post profiles (1 per client), Reliability &Validity information, and the User Guide/Manual. Small Kit - 50 questionnaires and 25 pre-post profiles Large Kit - 200 questionnaires and 100 pre-post profiles
*BADDS Auto-calculation Sheet - Interactive PDF that automatically calculates BADDS scale scores.
Small Starter Kits - 30-day trial (see page 10)
Large Starter Kits
Kit Contents:
Adult SASSI-4Adolescent SASSI-A2Combination Adult/AdolescentSpanish SASSIBADDS PretestBADDS Pretest w/auto-calculation sheet*BADDS Pre-PosttestBADDS Pre-Posttest w/ auto-calculation sheet*
Adult SASSI-4Adolescent SASSI-A2Combination Adult/AdolescentSpanish SASSIBADDS PretestBADDS Pretest w/auto-calculation sheet*BADDS Pre-PosttestBADDS Pre-Posttest w/ auto-calculation sheet*
Price$140.00$140.00$265.00$65.00$110.00$185.00$145.00$220.00
Price$250.00$250.00$485.00$195.00$225.00$305.00$360.00$435.00
K401K202K423EK101SMBKSMBKSMABKPSMBKPSMA
K401LK202LK423LEK101LGBKLGBKLGABKPLGBKPLGA
Product Code
Product Code
6
Education Substance Abuse Treatment Programs Hospitals Probation Assessment MilitaryJails
Paper & Pencil Pricing continued
Quantity (# of forms)
4 pkgs (100)
16 pkgs (400)
20 pkgs (500)
40 pkgs (1,000)
100 pkgs (2,500)
24 pkgs (600)
200 pkgs (5,000)
Per Pkg$41.25
$40.00
$38.75
$35.00
$33.75
$37.50
$32.50
Total Price$165.00
$640.00
$775.00
$1,400.00
$3,375.00
$900.00
$6,500.00
BADDS Volume Discounts
Per Pkg$180.00
$175.00
$170.00
$150.00
$135.00
$165.00
Total Price$720.00
$875.00
$1,020.00
$3,750.00
$6,750.00
$1,650.00
4 pkgs (400)
5 pkgs (500)
6 pkgs (600)
25 pkgs(2500)
50 pkgs (5000)
10 pkgs (1000)
Quantity (# of forms)
SASSI Volume Discounts
BADDS Auto-Calculation SheetAuto-Calculation Score Sheets
Price$80.00
Product CodeBAF
SASSI-4, SASSI-A2, Spanish SASSI & BADDS Paper Sets SASSI sets include questionnaires and profiles BADDS sets include questionnaires pre and posttest profiles
*Large Combination Adult/Adolescent Set contains 50 Adult and 50 Adolescent questionnaires and profiles.
Audio Recording Adult SASSI-4Adolescent SASSI-A2Spanish SASSI
Scoring Keys
User Guides & Manuals
Adult SASSI-4Adolescent SASSI-A2Combo* Adult/AdolescentSpanish SASSI
Adult SASSI-4Adolescent SASSI-A2Spanish SASSIBADDS
Adult SASSI-4Adolescent SASSI-A2Spanish Key
SASSI-4 User Guide/ManualSASSI-A2 User GuideSASSI-A2 ManualBADDS User Guide/ManualSpanish SASSI Administration & Scoring Instructions
Price$25.00$25.00$25.00
Price$60.00$60.00$60.00$45.00
Price$190.00$190.00$195.00$190.00
Price$10.00$10.00$10.00
Price$80.00$35.00$45.00$75.00 $5.00
Small Set (pkg of 25)
Large Set (pkg of 100)
P401SMP202SME101SMBSM
Product Code
P401LGP202LGK423LGE101LG
Product Code
K401KEYK202KEYE101KEY
Product Code
P401UGMP202UG MB202BUGME101AI
Product Code
P401CD P202CDE101CD
Product Code
SASSI-4 User Guide/Manual provides non-technical, step-by-step information on administering and scoring the SASSI-4, information on interpreting profiles and sample case profiles. It also provides detailed information on the development and validation of the SASSI-4 measures.
SASSI-A2 User Guide provides non-technical, step-by-step information on administering and scoring the SASSI-A2,information on interpreting profiles and sample case profiles.
SASSI-A2 Manual provides detailed information on the development and validation of the SASSI-A2 and contains a section on specific clinical issues.
BADDS User Guide/Manual provides empirical research on the development of the BADDS, detailed instructions on administration & scoring, guidelines for interpreting results, and sample profile reports.
Spanish SASSI Administration & Scoring Instructions provides information on the development of the Spanish SASSI, detailed instructions on administration & scoring, and guidelines for interpreting the results.
Audio CD is for clients who have reading difficulties, it is a professionally read version of the SASSI questionnaire on CD.
BADDS Auto-Calculation Sheet is an interactive PDF that automatically calculates BADDS scale scores. Includes the Individual Profile Score Calculation Sheet that calculates total scale scores for each client and provides brief narrative statements regarding level of impaired driving risk, and the Class/Group Score Calculation Sheet that calculates percentages and averages for group scores. Shows change in scores following intervention.
7
*The SASSI Institute's Online Security Commitment ensures our systems and processes will meet or exceed all state and federal regulations including HIPAA, 42CFR, and other regulations regarding confidential client data. We encrypt all data transmissions and de-identify client information. Identifiable client information is maintained as encrypted data. The SASSI Institute will not release client identifiable information without the express written consent of the client.
Overview: SASSI Online is a web-based system for the administration and scoring of SASSI questionnaires. Through your secure workspace, backed by our Security Commitment*, SASSI Online enables you to administer questionnaires, receive immediate scoring of clients’ responses, review client results and profile reports, all using a standard web browser and an Internet connection.
For larger quantities please call for pricing.
Price PerQuestionnaire Administration
Quantity
1-9
10-24
25-49
100-499
500-999
1,000
$12.50
$10.00
$8.50
$7.25
$6.50
$5.50
50-99 $8.25
Available Questionnaires: Adult SASSI-4, Adolescent SASSI-A2, and Spanish SASSI
SASSI Online benefits include:
• Multiple Delivery Options - Immediate access, that allows the client to enter their responses, through an emailed link, or while in the counselor’s office. Our paper delivery option, that allows questionnaires to be downloaded, printed, and given to the client to complete. Once complete the counselor enters the responses into an entry form.
• Web Accessible & Compatible - Supports almost all common browsers, and devices including tablets & smartphones.
• Immediate Results that include the decision rule outcome, a graph of the client’s scale scores, and a narrative report on the client’s SASSI scores.
• Flexible Purchase Options - SASSI Online is our only format that allows single license purchasing.
• – SASSI to Go is a small user-friendly application that is downloaded to a laptop or thumb drive, then assessments are administered to clients with or without an Internet connection. Once a computer with Internet connection becomes available, upload those assessments to SASSI Online to view the client reports.
PricingnlineSASSIPrivate Practice Drug Courts Employee Assistance Programs SBIRT
SASSI to G
8
Student Assistance Veterans Department of Transportation Evaluations Workforce Development ASL
TrainingOverview: The SASSI Institute provides quality training for using our screening questionnaires. We striveto provide the best professionals in the U.S. and Canada to facilitate our training workshops. Training is offered in live hands-on settings locally or via live and recorded webinars online.
Continuing Education Credits: Our workshops are approved by these professional organizations:
Workshops AvailableSASSI Training - 3.5 CEs per session
Session I: Administration & ScoringParticipants will learn how the SASSI was developed and how it should be used, administration & scoring of the adult and adolescent SASSI questionnaires, and basic knowledge of the individual scales. No prior experience with the SASSI required. Upon completion of this session, participants will be able to use both the adult (SASSI-4) and adolescent (SASSI-A2) versions of the SASSI as an addiction screening tool. The Spanish SASSI is also briefly covered.
Session II: Clinical InterpretationParticipants will learn the clinical use of the SASSI scales, screening and assessment information, and how to give feedback to the client. Upon completion of this session, participants will feel comfortable making clinical interpretations from both the adult & adolescent SASSI scales and using the SASSI as a tool to en-gage the client in the treatment process.
BADDS Training - 3.5 CEsParticipants will learn about the need for and history of the BADDS, how to be proficient in administering, scoring, and interpreting the BADDS, how to relate BADDS responses to potential interventions and pre-screening for high probability of substance use. Upon completion of this training, participants will be able to proficiently use the BADDS to identify an individual's risk of future impaired driving and riding behaviors as well as using the BADDS to assess the immediate impact of an intervention.
SAVR-S2 Learning ModuleThis is a recorded online module which we provide free of charge. Participants will develop a working know-ledge of how to use, interpret, and benefit from the SAVR-S2 and gain an understanding of how the SAVR-S2 can assist in identifying specific client needs which may lead to improved client treatment outcomes. Optional .5 CE available with the successful completion of a post-test and $5 fee.
For pricing, additional information, or assistance in locating training in your area or online please visit www.sassitraining.com or call the training office at 800-697-2774.
National Association of Alcohol & Drug Abuse Counselors* (NAADAC), American Probation and Parole Association (APPA),
California Consortium of Addiction Programs and Professionals (CCAPP), and Texas Certification Board of Addiction Professionals (TCBAP)
*NAADAC CEs are accepted by many other boards and organizations. A complete listing can be found at: http://www.naadac.org/naadacceacceptance
Workshops in Canada are approved by the Canadian Addiction Counsellors Certification Federation (CACCF).
9
DUI Evaluations Welfare Drug Courts Jails Program Evaluation
Scantron/Optical Scanning PricingOverview: Electronically scanned forms provide rapid scoring for programs that conduct a large number of substance use evaluations. Reports can be customized on a contractual basis to meet program needs.
Please call customer service if you are interested in implementing the Scantron SASSI.
Scantron results include decision rules, graph of client scores, and narrative client reports.
Adult Forms OnlyAdolescent Forms Only
Product CodeS401
S102NC
Quantity100
500
1,000
2,500
1,500
Per Form$7.20
$6.55
$4.50
$3.05
$4.10
Total Price$720.00
$3,275.00
$4,500.00
$7,625.00
$6,150.00
For larger quantities please call for pricing.
Forms sold in packages of 100.
Scoring & Report Service (SRS)
Overview: Through our Scoring & Report Service (SRS) the counselor downloads and prints the quest-ionnaire at www.sassi-srs.com and then faxes the client-completed form to our automated system which scores it and returns an interpretive report. The report includes each client’s overall screening result, as well as identific-ation of key issues affecting each client. Reports are delivered within two business days via e-mail.
For larger quantities please call for pricing.
Quantity1-9
10-24
25-49
100-499
500-999
1000
50-99
Price PerReport$12.50
$10.00
$8.50
$7.25
$6.50
$5.50
$8.25
Available Questionnaires: SAS-ASL and SAVR-S2
SAS-ASL includes a video in American Sign LanguageSAVR-S2 is also available in large print & Braille
Please call customer service to set up an account with our Scoring & Report Service
10
Small Starter Kits - 30-day trialTo guarantee your satisfaction and ensure that our questionnaires will be useful in your practice, you may try a Small Starter Kit for thirty (30) days at no risk. At the end of the thirty (30) day trial period you will have an additional thirty (30) days to either pay the invoice or, if you decide not to keep the Starter Kit, send back the remaining materials and we will credit your account for the invoice total. Trial option not available on Large Starter Kits.
All other purchasesIf your order is found to be incorrect it may be returned for exchange or credit within sixty (60) days from date of purchase. If your order has been damaged in shipping please retain all of the original packaging and call Customer Service at 800.726.0526 for assistance.
Any items advertised in our current catalog may be exchanged within one (1) year from date of purchase if they are in saleable condition. These items may be subject to a 15% re-stocking fee.
Original shipping & handling costs are not refundable and customer is responsible for shipping charges on returned materials. Please call Customer Service at 800.726.0526 to obtain a Return Merchandise Authorization (RMA) number. We recommend you carefully package and insure return shipments. We will not accept damaged or non-saleable materials and are not responsible for lost or returned ship-ments.
Return Policy
Copyright NoticeThe SASSI instruments and BADDS are copyrighted instruments, which includes the questionnaires, profiles, questionnaire items, T scores, scales, norms, score reports, scoring keys, and all related materials and, as such, they are protected by the copyright laws of the United States, Canada, and other countries. They may not be reproduced or transmitted in whole or in part, in any form or by any means, including creating derivative products or presentations, copying into computer storage media of any kind, copying onto audiovisual storage media, photocopying, or copying of any other kind without prior written perm-ission of the publisher. Unauthorized reproduction of any part of the copyrighted materials is unethical as well as a violation of federal copyright laws.
Questions are not to be reproduced, paraphrased, or translated in any way. The SASSI Institute, Inc. and Jewell & Hupp, L.L.P. make no estimate of accuracy for questionnaire items that have been paraphrased, translated, or for screening accuracy resulting from administration of only selected test items on the instruments.
Education Substance Abuse Treatment Programs Hospitals Probation Assessment MilitaryJails
Prior to processing your order, this form must be completed and signed by an individual who meets one of the following professional qualifications and who is authorized to sign for the undersigned organization:
Please mark the item which best describes your professional qualification:
Please mark the item which best describes your current work setting (mark all that apply):
11-02-10
Organization Name:
Address:
City, State, & Zip:
Fax:Phone: E-mail:
Name:(Please print)
Title:
How did you first hear/find out about The SASSI Institute (please supply specifics and mark all that apply):
Mandated use Internet Word of mouth SASSI Institute newsletter Current setting uses: SASSI BADDS SASSI Institute information packet Used before in another position Published articles Journal ads: SASSI Training Conference: Name & Date: Other (specify):
Military Welfare, Child Protective Services Workforce Development Vocational Rehabilitation EAP, Union, DOT-SAP Secondary/College Education Private Practice
Substance Abuse Treatment Program Medical, Hospital, HMO Behavioral Health Facility Jail, Prison Probation, Parole, Pre-sentencing Drug Court Other (specify):
Lic./Cert. Psychologist Lic./Cert. Social Worker Psychiatrist or other MD Lic./Cert. Rehabilitation Counselor (e.g., CRC, Rh.D.) Licensed Psychiatric Nurse Research Ph.D./Clinical Ph.D. Lic./Cert. Addictions Counselor (e.g., CADC, LCDC) IC&RC (e.g., AODA, CCJP, CCDP) Lic./Cert. Counselor/Therapist (e.g., LMFT, LPC) Specify: Other Lic. or Cert.(specify): Training (specify): Non-licensed or certified (fill out additional info): SASSI Other: Educational background: City & State: Major: Trainer Name: Degree: Year: Month: Year:
Date:(Please sign name)
By:
Purchaser agrees to indemnify and hold The SASSI Institute and its owners, officers, directors, employees, indepen-dent contractors, suppliers, and affiliated parties harmless against all claims, liabilities, demands, damages, judg-ments, settlements, or expenses of whatever nature (including reasonable attorneys’ fees and expenses) arising out of or in connection with the use or misuse of tests or test materials, scoring, or other services connected to test administration of substance use measures created by and/or distributed by The SASSI Institute.
U.S. Qualification Form
U.S. Order Form
For repeat orders,please indicateCustomer ID (if known)
The information contained on this form is confidential.We do not sell or share your
information with anyone.
For initial orders, please include a completed Qualification Form (see p. 3 for qualifications)
Date
Purchase Order Number (If required)
Customer Name (if different than below) E-mail Address
Customer ID Number (Repeat orders only)
INVOICE TO:Name
Organization Phone
Mailing Address Fax
City State/Zip
SHIP TO:Name (if different than above)
Organization Phone
Street Address Fax
City State/Zip
Phone: 800.726.0526 Mail: 201 Camelot Lane Springville, IN 47462 Fax: 800.546.7995 Web: www.sassi.comFOUR WAYS TO ORDER:
U.S
. O
rder
For
m
U.S
. O
rder
For
m
*Your CVV Code is a verification code printed on your credit card. On the American Express card it is a 4 digit number located on the front of the card. On Visa, MasterCard, and Discover it is a 3 digit number located on the back of the card on the signature line (the last 3 digits).
Method of Payment:
Visa
Check EnclosedInvoice (Net 30-Days)
MasterCard
American Express Discover
Name of Card Holder (Printed)
Credit Card Number
CVV Code*(required)
Signature of Card Holder
Expiration Date
Thank you
for your order
!
Product Code Product Description Quantity Price Per Item Total
Subtotal:
Sales tax:Indiana Only
Shipping/Handling:
ProductTotal:
Total:
United States Shipping Fees
For Next Day Air, 2nd Day Air, or 3 Day Select shipping rates, please call customer service. All Alaska and Hawaii orders will be
shipped via USPS Priority Mail.
Order Total$0-$40$41-$70$71-$125$126-$250$251-$500$501-$800$801-$1000
ShippingCost$7$11$13$15$20$23$26
Order Total$1001-$1250$1251-$1400$1401-$1700$1701-$2100$2101-$2500$2501-$2900*
*For orders exceeding $2900.00 call for quote
ShippingCost$30$34$38$42$47$54
Zip Code on Card (required)
Prior to processing your order, this form must be completed and signed by an individual who meets one of the following professional qualifications and who is authorized to sign for the undersigned organization:
Please mark the item which best describes your professional qualification:
Please mark the item which best describes your current work setting (mark all that apply):
Substance Abuse Treatment Program Medical, Hospital, HMO Behavioral Health Facility Jail, Prison Probation, Parole, Pre-sentencing Drug Court Other (specify):
Military Welfare, Child Protective Services Workforce Development Vocational Rehabilitation EAP, Union, DOT-SAP Secondary/College Education Private Practice
11-02-10
Organization Name:
Address:
City, Province, & Postal Code:
Fax:Phone: E-mail:
Name:(Please print)
Title:
How did you first hear/find out about the SASSI Institute (please supply specifics and mark all that apply):
Mandated use Internet Word of mouth SASSI Institute newsletter Current setting uses: SASSI BADDS SASSI Institute information packet Used before in another position Published articles Journal ads: SASSI Training Conference: Name & Date: Other (specify):
Date:(Please sign name)
By:
Purchaser agrees to indemnify and hold the SASSI Canada a division of 1303821 Ontario Inc., 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 tests or test materials, scoring, or other services connected to test administration of substance use measures created by and/or distributed by SASSI Canada.
Canada Qualification FormCANADA
Lic./Cert. Psychologist Lic./Cert. Social Worker Psychiatrist or other MD Lic./Cert. Rehabilitation Counselor (e.g., CRC, Rh.D.) Licensed Psychiatric Nurse Research Ph.D./Clinical Ph.D. Lic./Cert. Addictions Counselor (e.g., CADC, LCDC) IC&RC (e.g., AODA, CCJP, CCDP) Lic./Cert. Counselor/Therapist (e.g., LMFT, LPC) Specify: Other Lic. or Cert.(specify): Training (specify): Non-licensed or certified (fill out additional info): SASSI Other: Educational background: City & State: Major: Trainer Name: Degree: Year: Month: Year:
For repeat orders,please indicateCustomer ID (if known)
The information contained on this form is confidential.We do not sell or share your information with anyone.
Can
ada
Ord
er F
orm
Can
ada
Ord
er F
orm
Canada Order Form
Date
Purchase Order Number (If required)
Customer Name (if different than below) E-mail Address
Customer ID Number (Repeat orders only)
INVOICE TO:Name
Organization Phone
Mailing Address Fax
City Province/Postal Code
SHIP TO:Name (if different than above)
Organization Phone
Street Address Fax
City Province/Postal Code
Phone: 800.726.0526 Mail: 201 Camelot Lane Springville, IN 47462 Fax: 800.546.7995 THREE WAYS TO ORDER:
For initial orders, please include a completed Qualification Form (see p. 3 for qualifications)
Thank you
for your order
!
Product Code Product Description Quantity Price Per Item Total
Subtotal:
ProvinceSales tax:If Applicable
Canadian Funds
Shipping/Handling:
ProductTotal:
Total:
Canada Shipping Information
Orders shipped to the Yukon or Northwest Territories are sent via USPS only. All other orders shipped to Canada are sent at the best available rate via USPS or UPS. If you would like a shipping quote before placing your order, please contact Customer Service 1.800.726.0526.
*Your CVV Code is a verification code printed on your credit card. It’s a 3 digit number located on the back of the card on the signature line (the last 3 digits).
Method of Payment:
Visa (Only VISA Accepted)
Check Enclosed
Invoice (Net 30-Days)
Name of Card Holder (Printed)
Credit Card Number
CVV Code* (required)
Signature of Card Holder
Expiration Date
Postal Code on Card (required)
Program Evaluation
11
Private Practice Drug Courts Employee Assistance Programs SBIRT
Our clinicians are available to assist you with FREE consultation and help with administration, scoring and interpretation for all of our instruments.
888.297.2774
Canada Shipping InformationOrders shipped to the Yukon or Northwest Territories are sent via USPS only. All other orders shipped to Canada are sent at the best available rate via USPS or UPS. If you would like a shipping quote before placing your order, please
contact Customer Service 800.726.0526.
Shipping Information
United States Shipping Fees
For Next Day Air, 2nd Day Air, or 3 Day Select shipping rates, please call customer service.
All Alaska and Hawaii orders will be shipped via USPS Priority Mail.
*For orders exceeding $2,900.00 and all foreign countries, please call for shipping charges.
Order Total$0-$40$41-$70$71-$125$126-$250$251-$500$501-$800
$801-$1,000
ShippingCost$7$11$13$15$20$23$26
Order Total$1,001-$1,250$1,251-$1,400$1,401-$1,700$1,701-$2,100$2,101-$2,500$2,501-$2,900*
ShippingCost$30$34$38$42$47$54
Orders received before 5 p.m. eastern time will be shipped the next business day.
Orders are shipped the best way, either United Parcel Service (UPS) ground or Post Office (USPS). Rush orders in the US are shipped by UPS (Next day air, 2nd day air, or 3 day select) for an additional fee. Rush orders in Canada are shipped by UPS Worldwide Express Plus, Express, or Expedited (not available in all
areas) for an additional fee. For rush orders or questions about shipping, please call Customer Service at 800.726.0526.
Shipping Policy
N03PC
Free Clinical Consultation: 888.297.2774
201 Camelot LanePhone: 800.726.0526
www.sassi.com
|||
Springville, IN 47462Fax: [email protected]
At The SASSI Institute we are committed tohelping people who su�er from substance use problems
and the professionals who serve them.
The SASSI Institute
