This form is required for any clinical uses of the SASB questionnaires or software.

*******************************************************************

Section I. To be completed by the person responsible for test interpretation

NAME:___________________________________________________________

TITLE:__________________________________________________________

ORGANIZATION NAME:______________________________________________

ORGANIZATION ADDRESS:___________________________________________

CITY____________________________________STATE____ZIPCODE______

TELEPHONE_____________________________________________________

CERTIFICATION AND LICENSING

State, Certificate or license title and number. Expiration Date

________________________________________________________________

Profession for which the license is issued (e.g., psychologist, psychiatrist, social worker):

________________________________________________________________

Training in the clinical use of the SASB model (include place, instructor, dates).

________________________________________________________________

Training in the practice of Psychotherapy:

Highest Year College/University Major Field

degree

_______________________________________________________________

Supervised clinical training for object-relations oriented psychotherapy . Include places, supervisors and dates:

________________________________________________________________

________________________________________________________________

________________________________________________________________

I certify that I will administer and interpret the clinical Intrex report in accordance with the "Ethical Principles of Psychologists" (Copies available from the American Psychological Association, 1200 Seventeenth Street, N.W., Washington, D.C., 20036). I also certify that I will use the Intrex report collaboratively with patients with the goal of enhancing their psychotherapy. I understand that the Intrex is not an objective instrument appropriate for making administrative or legal decisions.

SIGNATURE___________________________________________DATE______

****************************************************************

Section II

To be completed by an authorized representative of the organization (This can be the same person as above:) I certify that this institution has and will continue to have internal quality control procedures that will insure that professional staff meet the ethical standards specified by the American Psychological Association, and that they meet the standards for service providers consistent with our State law.

SIGNATURE___________________________________________________

TITLE_________________________________________DATE_________