Name______1

CHECKMATE PLUS 2015ORDER FORM

CATALOG # / PRODUCT DESCRIPTION / UNIT PRICE / QTY / TOTAL
CSI-DK / CHILD SYMPTOM INVENTORY-4 (CSI-4) DELUXE KIT / $119.00
CSI-CM / CSI-4 CONSOLIDATED MANUAL (Screening & Norms Manuals Combined) / $54.00
CSI-P50 / CSI-4 PARENT CHECKLIST (pkg. 50) / $40.00
CSI-P50SP / CSI-4 PARENT CHECKLIST IN SPANISH (pkg. 50) / $40.00
CSI-P100 / CSI-4 PARENT CHECKLIST (pkg. 100) / $73.00
CSI-P100SP / CSI-4 PARENT CHECKLIST IN SPANISH (pkg. 100) / $73.00
CSI-T50 / CSI-4 TEACHER CHECKLIST (pkg. 50) / $40.00
CSI-T100 / CSI-4 TEACHER CHECKLIST (pkg. 100) / $73.00
CSI-PSS / CSI-4 PARENT SYMPTOM SEVERITY PROFILES (pkg.50) / $17.00
CSI-TSS / CSI-4 TEACHER SYMPTOM SEVERITY PROFILES (pkg.50) / $17.00
ASI-DK / ADOLESCENT SYMPTOM INVENTORY-4 (ASI-4) DELUXE KIT / $124.00
ASI-CM / ASI-4 CONSOLIDATED MANUAL (Screening & Norms Manuals Combined) / $54.00
ASI-50 / ASI-4 PARENT CHECKLIST (pkg. 50) / $63.00
ASI-50SP / ASI-4 PARENT CHECKLIST IN SPANISH (pkg. 50) / $63.00
ASI-T50 / ASI-4 TEACHER CHECKLIST (pkg. 50) / $47.00
ASI-PP / ASI-4 PARENT SYMPTOM SEVERITY PROFILES (pkg. 50) / $17.00
ASI-TP / ASI-4 TEACHER SYMPTOM SEVERITY PROFILES (pkg. 50) / $17.00
YI-DK / YOUTH=S INVENTORY-4 (YI-4) SELF-REPORT DELUXE KIT / $92.00
YI-M / YI-4 MANUAL / $27.00
YI-50 / YI-4 CHECKLISTS (pkg. 50) / $63.00
YI-50SP / YI-4 CHECKLISTS IN SPANISH (pkg. 50) / $63.00
YI-P / YI-4 SYMPTOM SEVERITY PROFILES (pkg. 50) / $17.00
ECI-DK / EARLY CHILDHOOD INVENTORY-5 (ECI-5) DELUXE KIT / $124.00
ECI-SM / ECI-4 SCREENING MANUAL / $27.00
ECI-4 NM / ECI-4 NORMS MANUAL / $27.00
ECI-P50 / ECI-5 PARENT CHECKLIST (pkg. 50) / $63.00
ECI-P50SP / ECI-4 PARENT CHECKLIST IN SPANISH (pkg. 50) / $63.00
ECI-T50 / ECI-5 TEACHER CHECKLIST (pkg. 50) / $63.00

Name______1

CATALOG # / PRODUCT DESCRIPTION / UNIT PRICE / QTY / TOTAL
ECI-PSS / ECI-5 PARENT SYMPTOM SEVERITY PROFILES (pkg. 50) / $17.00
ECI-TSS / ECI-5 TEACHER SYMPTOM SEVERITY PROFILES (pkg. 50) / $17.00
SC4-K / ADHD SYMPTOM MONITOR CHECKLIST - 4 KIT / $63.00
SC4-M / ADHD-SC4 MANUAL / $27.00
SC4-50 / ADHD-SC4 CHECKLISTS (pkg. 50) / $32.00
SC4-100 / ADHD-SC4 CHECKLISTS (pkg. 100) / $59.00
SC4-SSP / ADHD-SC4 SYMPTOM SEVERITY PROFILES (pkg. 50) / $12.00
CASI-PM-K / Child & Adolescent Symptom Inventory Progress Monitor (CASI-PM) KIT / $63.00
CASI-PM-50P / CASI-PM PARENT CHECKLISTS (PKG.50) / $32.00
CASI-PM-50T / CASI-PM TEACHER CHECKLISTS (PKG.50) / $32.00
CASI-PM-M / CASI-PM MANUAL / $22.00
CASI-PM-100P / CASI-PM PARENT CHECKLISTS (PKG.100) / $59.00
CASI-PM-100T / CASI-PM TEACHER CHECKLISTS (PKG.100) / $59.00
CASI5-DK / Child & Adolescent Symptom Inventory-5 (CASI-5) DELUXE KIT / $154.00
CASI5-50P / CASI-5 PARENT CHECKLISTS (pkg. 50) / $63.00
CASI5-50T / CASI-5 TEACHER CHECKLISTS (pkg. 50) / $63.00
CASI5-PP / CASI-5 PARENT SYMPTOM SEVERITY PROFILES (25 Child25Adolescent) / $17.00
CASI5-TP / CASI-5 TEACHER SYMPTOM SEVERITY PROFILES (25 Child25Adolescent) / $17.00
SOC / ADHD SCHOOL OBSERVATION CODE KIT / $31.00
AI-DK / ADULT INVENTORIES-4 DELUXE KIT / $124.00
ASRI-50 / ADULT SELF-REPORT INVENTORY-4 (ASRI-4) CHECKLIST (pkg. 50) / $63.00
ASRI-50SP / ADULT SELF-REPORT INVENTORY-4 CHECKLIST in SPANISH (pkg. 50) / $63.00
AI-50 / ADULT INVENTORY-4 CHECKLIST (pkg. 50) / $63.00
AI-50SP / ADULT INVENTORY-4 CHECKLIST in SPANISH (pkg. 50) / $63.00
ASRI-SSP / SYMPTOM SEVERITY PROFILES for the ASRI (pkg. 50) / $17.00
ASRI-M / ADULT INVENTORY-4 MANUAL / $49.00

ORDER SUBTOTAL______

POSTAGE & HANDLING______

(Calculated by weight by carrier)______

NY State residents add 8 ¾% Sales Tax______

Indiana residents add 7% Sales Tax

TOTAL______

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