ADOS reg_order form_0510 by suchenfz


									                Workshops on the
   Autism Diagnostic Observation Schedule (ADOS)
                                                                  sponsored by Western Psychological Services

                                                                    Registration Form
Dates and Locations                                                                           Registration Packet
  For the latest information on dates and locations of ADOS workshops                         Upon registration, each participant will be sent a registration packet.
                visit our website at                                       (Please allow 2 weeks for delivery.) This packet will include information
                   or call Melissa Prejean: 800-648-8857                                      about the workshop and accommodations, plus a DVD and ADOS
                                                                                              Observation/Coding Booklet, both of which should be reviewed prior to
 Please indicate the Dates and Location of the course you are registering for:
                                                                                              the workshop. Please indicate below where you would like the
 __________________________________________________________________________________           registration packet(s) sent. When one organization pays for multiple
                                                                                              registrants, all packets will be mailed to one address.
                                                                                              □ Home    or   □ Work Address:
Workshop cost is $369.00 for the complete 2-day course, including                             Organization : _________________________________________________________________________
two DVDs, Observation/Coding Booklets, and accompanying
                                                                                              Street Address: _______________________________________________________________________
materials. Organizations registering 5 or more people qualify for a
10% discount off total registration cost as long as all registrations                         City: ________________________________________________ State: _________ Zip: ____________

are paid with one credit card authorization or check. For late                                Phone: ______________________________________________________________________________
registration (less than 2 weeks before workshop date), please add
                                                                                              FAX: ________________________________________________________________________________
$35.00 to cover the cost of late registration.
                                                                                              E-mail: ______________________________________________________________________________
Number of Registrants: _____________________ Total Cost: ________________________________
□ Check enclosed        Please charge my: □ Visa   □ MasterCard     □ American Express        If 2 weeks prior to the workshop you have not yet received your
                                                                                              registration packet, please call WPS: 800-648-8857
Credit Card Number: ___________________________________________ Exp. Date:_______________

Name on Credit Card:_______________________________________________ Security Code: ________   Required Materials
Signature: ____________________________________________________________________________       Registrants are required to bring an ADOS manual to the
Billing Address: ________________________________________________________________________     workshop. The manual can be purchased online at
                                                                                     Product number: W-365B.
City:_________________________________________________ State: _________ Zip: ____________

Please list all registrants and their license numbers:                                        Continuing Education Hours
                                                                                              The ADOS workshop represents 12 contact hours of continuing
Name: _______________________________________________________________________________
                                                                                              education. Western Psychological Services is approved by the
Profession: ___________________________________________ License No.: ______________________
                                                                                              American Psychological Association to sponsor continuing education
Name: _______________________________________________________________________________
                                                                                              for psychologists. In addition, WPS is an American Occupational
Profession: ___________________________________________ License No.: ______________________
                                                                                              Therapy Association Approved Provider of continuing education. (The
Name: _______________________________________________________________________________
                                                                                              assignment of AOTA CEUs does not imply endorsement of specific
Profession: ___________________________________________ License No.: ______________________
                                                                                              course content, products, or clinical procedures by AOTA.) The
Name: _______________________________________________________________________________
                                                                                              National Association of Alcohol and Drug Abuse Counselors
Profession: ___________________________________________ License No.: ______________________
                                                                                              (NAADAC) has approved the WPS CE course offering. The California
Name: _______________________________________________________________________________
                                                                                              Board of Behavioral Sciences has authorized WPS to offer continuing
Profession: ___________________________________________ License No.: ______________________
                                                                                              education for marriage and family therapists, licensed clinical social
Organization:__________________________________________________________________________       workers, and licensed educational psychologists (Provider Number
We suggest you wait to make travel plans until your registration is confirmed.                PCE2790). Western Psychological Services (WPS) is approved by
                                                                                              the National Association of School Psychologists (NASP) to offer
Refund Policy                                                                                 continuing education for school psychologists. WPS maintains
To cancel your registration and receive a refund (less a $25.00                               responsibility for this program and its content.
administrative fee), you must notify WPS in writing at least 14 days prior
to the course start date. Cancellations received less than 14 days before                                          Fax or Mail completed form,
the course start date will be subject to a $35.00 administrative fee. The                                  with check or credit card authorization, to:
registration packet must be returned to WPS, in good condition, along                                             Western Psychological Services
with your written request for cancellation. WPS will issue a refund only                               12031 Wilshire Boulevard, Los Angeles, CA 90025-1251
when these materials have been returned. If you are unable to return                                                  Fax No. 310-478-7838
them, a $75.00 fee will apply.
Autism Diagnostic                                                                                                    ORDER FORM
Observation Schedule                                                                             Western Psychological Services
(ADOS)                                                                                           12031 Wilshire Blvd., Los Angeles, CA 90025-1251

                                                                           Product No.                       Price                            Quantity                   Cost
    Kit                                                                      W-365                        $1,480.00
      16 Observation/Coding Booklets (4 for each Module)
      Test Materials (More than 85 Stimulus Materials,
        12 Laminated Cartoons, 3 color Picture Cards)
      All in a sturdy plastic carrying bin, with handles

                      INDIVIDUAL COMPONENTS
    Observation/Coding Booklet                                              W-365A                   1 Pkg. @ $45.00
     (Pkgs. of 10)                                                                                 2+ Pkgs. @ $42.00 each

       Please specify:
           Module 1                                                                                                                      ____ Module 1
           Module 2                                                                                                                      ____ Module 2
           Module 3                                                                                                                      ____ Module 3
           Module 4                                                                                                                      ____ Module 4

    Manual                                                                 W-365B                          $67.00

                         TRAINING MATERIALS
    ADOS DVD Training Package                                              W-365DVD                      $797.50
     Includes Training DVD with Practice Administration 1
     and Practice Administration 2, Guidebook,
     Set of 6 Blank Observation/Coding Booklets

    CE Questionnaire and Evaluation Form                                   W-365CE                       $198.00
     To receive 18 CE credits for mastering the ADOS Training
      Package,you must complete and return these materials.

                                                                                                                                            Cost of Materials

                     email: c u s t o m e r s e r v i c e @ w p s p u b l i s h . c o m
                                                                                                                                    Shipping and Handling
                                                                                                                                  (U.S. 10%, with $5.00 minimum;
                                                                                                                              Canada 20%, with $10.00 minimum;
                                                                                                                         other foreign 25%, with $25.00 minimum)

Method of Payment: □                                □                  □                 □    Payment enclosed                                            Subtotal

Card                                                                        Expiration
Account                                                                     Date                                                     Sales Tax on Subtotal
Number                                                                      (Required)                                                               (California only)

NAME ON CREDIT CARD                                                         SECURITY CODE (Required)
                                                                                                                                               TOTAL DUE



                                                                                                                                   Credit card orders call toll free

                                                                                                                                    7:30 a.m. – 4:30 p.m. Pacific Time

CITY/STATE/ZIP                                                                                                                      FAX: 310-478-7838
(                )
TELEPHONE                                    HIGHEST ACADEMIC DEGREE              E-MAIL ADDRESS

                                                                                                                     Prices are subject to change.                              5 /10

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