Qualification For Purchase of SASSI Products

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.

*Fields marked with a red asterisk are required.
v9.17.07
Full Name: *
Organization: *
Address: *
City: *
State: *
Zip: *
Phone Number: *
Fax:
E-mail: *
Please select the location to which this information refers
Home Work
Please mark the item which best describes your professional qualification.
Lic./Cert. Psychologist Lic./Cert. Social Worker
Psychiatrist or other MD Research Ph.D / Clinical Ph.D
Licensed Psychiatric Nurse SASSI Training (Please Fill in Info Below)
Lic./Cert. Addictions Counselor
Location:
Given By:
Date:
Lic./Cert. Counselor/Therapist
Other License or Certificate (specify below)
Other:
Non-licensed or certified (fill out below)
Fill out ONLY if you checked the Non-licensed or Certified button
Educational Background
Degree:
Major:
College/ University:
Year:
Relevant Professional Experience
Date:
Organization:
Position:
Assessment Tools Used:
Please mark the items which best describe your current work setting (mark all that apply)
Substance Abuse Treatment Program Military
Medical, Hospital, HMO Welfare, Child Protective Services
Behavioral Health Facility Workforce Development
Jail, Prison Vocational Rehabilitation
Probation, Parole, Pre-sentencing EAP, Union, DOT
Drug Court Education
Assessment Private Practice
Other
Other:
How did you hear/find out about the SASSI Institute (Mark all that apply)
SASSI Information Packet Internet
Mandated Use SASSI Newsletter
Word of Mouth Published articles
Current setting uses SASSI SASSI Training
Used before in another position Conference
Journal Ads Other
Are you supervising others in their use of SASSI assessment measures?   
If yes, please list supervisees’ names below:
Supervisee 1 -    
Supervisee 2 -    
Supervisee 3 -    
Supervisee 4 -    
By clicking Submit below you agree to the following terms:
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 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. Agree *
The SASSI Institute
201 Camelot Lane, Springville, IN
Customer Service Phone Number: 1-800-726-0526
Customer Service E-mail: sassi@sassi.com
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