Psychological Testing / Neurofeedback Qualification Form

BrainTrain's products are available only to clinicians and educators and are not intended for personal use. To purchase our products, you must be qualified as a professional mental health or healthcare provider, or as an educator.

BrainTrain's clinical decision support software testing systems - IVA-2, IVA-QS, IVA-AE, and MeSA-AE/IE - are sold only to professionals who meet Level B psychological testing guidelines in accordance with the Standards for Educational and Psychological Tests. To use this decision support software, you must meet the following minimum criteria:

Certification by or full active membership in a professional organization (ASHA, AOTA, APA, AERA, ACA, AMA, NASP, NAN, INS) that requires training and experience in a relevant area of assessment - OR - A Master's Degree in psychology, education, occupational therapy, speech-language pathology, social work, or in a field closely related to the intended use of the assessment, and formal training in the ethical administration, scoring, interpretation, and diagnostic use of clinical decision support software assessments.

User Information

Name*

First Last

First and Last name

Title

Title (Mr., Mrs., Dr., etc.)

Have you (or your facility) purchased BrainTrain software?*

Yes

Customer Number (if known)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Fax*

Email*

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Education

Highest Professional Degree Attained*

Major Field*

Year Graduated*

Institution Graduated From*

Valid License/Certificate Issued By State Regulatory Board

Certificate/License

State

Number

Exp. Date

Primary Type of Practice

Select*

Private Practice

Organization/Institution

Membership in Professional Organizations

Please Specify*

Professional Experience

Organization

Position

Test(s) Used

Organization

Position

Test(s) Used

Other Applicable Courses/Workshops Completed

Title

Institution

Date

Title

Institution

Date

Signature

Enter Your Name*

I hereby certify that I and/or other persons who may use the test materials ordered by me have a general knowledge of measurement principles and of the limitations of test interpretation as called for in the APA Standards for Educational and Psychological Tests. I also certify that I/we are qualified to use and interpret the results of these tests as recommended in the APA Standards.

Date*

This field is for validation purposes and should be left unchanged.

Psychological Testing / Neurofeedback Qualification Form

User Information

Education

Primary Type of Practice

Professional Experience

Other Applicable Courses/Workshops Completed

Signature

Licensing Agreement

Statement of Privacy

Terms of Use

508 Compliance