OQ®-Analyst Software License Application & Order Form (OT)

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This form is an agreement with OQ Measures to be able to deliver the OQ Measures surveys through OutcomeTools. Once this form has been submitted and payment received, the OQ Measures tools will be authorized to be turned on in OutcomeTools for delivery. This license must be renewed yearly.

Email *

Company Name

*Please Choose Any Three Instruments*

The Therapeutic Alliance(TA) surveys can be added in addition to the 3 instruments you choose

Untitled Title

Adult Instruments

OQ® 45.2

OQ® ASC

OQ® CSS

OQ® GQ

OQ® TA (does not count as one of the 3 instruments)

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Youth Instruments

Y-OQ® 2.01

Y-OQ® SR 2.0

Y-OQ® 30.2 SR/PR

Y-OQ® TSM Parent/Youth

Y-OQ® TA (does not count as one of the 3 instruments)

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Order Information

A) License Fee: $250 per 100 clients served. (e.g. if serving 200 clients per year, yearly fee would be $500)

B) Additional Measures (Beyond the First Three Measures - $40.00 Each, Per 100 clients served)

C) Additional Manuals ($25.00 Each)

D) Installation Fee and Technical Support: ($150.00) (REQUIRED)

E) Utah Residents must include Sales Tax (7.75%, do not include S&H in this taxed total)

F) Shipping and Handling ($25 Standard and $50 for International) (REQUIRED)

Subtotal: (Add lines A-D, add in sales tax, then include S&H to obtain Subtotal) Most totals will be $444.38 for Utah Residents ($250+19.38+150+25= $444.38) Will be greater if clients served is greater than 150 per year. *

Payment Information

Please make Checks Payable to: OQ Measures, LLC
Send to:
OQ Measures, LLC
P.O. Box 521047
Salt Lake City, UT 84152

Phone: 888-647-2673
Email: Office@ OQmeasures.com
Website: www.OQmeasures.com
Fax: (801)747-6900

Payment Information

Check (Sent to OQ Measures)

Credit Card Payment (An invoice will be sent from OQ Measures, please pay on arrival of invoice.)

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You MUST Provide us with both a clinical and technical contact to place an Order

Technical Contact: *

Technical Phone #:

Technical Email:

Fax #:

Other:

Shipping Information:

Clinical Contact: *

Clinical Phone #:

Clinical Email:

Organization:

Address (include city, state, zip and country):

OQ Analyst Software Initial Setup Questions

Please answer the following 5 questions. Providing this initial information will expedite the setup of your OQ®-Analyst software site. If you do not have this information available, please submit your order form without this information and our IT support team will be in contact soon to complete your setup.

1. Name of Organization (Max. 20 Characters including spaces):

2. Name of Clinic (Max. 20 Characters including spaces):

3. Setting of Care ( e.g. Outpatient. Max 25 characters including spaces):

4. First and Last name of primary user (System Admin):

5. Desired Username:

6. Email address (Primary user listed above):

7. Phone number (Primary user listed above):

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