American Psychiatric Publishing
A Division of American Psychiatric Association

Please allow up to 4 weeks for processing. Request will be processed in the order that they are received.


SECTION I. Contact Information:

* Name of Person Making the request:   
Name of Company or Organization:
* Address Line 1:   
Address line 2:
Address line 3:
* City:  
State:
Postal Code:
* Country:   
* Email Address for Contact Person (MUST be Vaild):   
Telephone Number for Contact Person: 
Facsimile Number for Contact Person: 
Are you the author of the material you are requesting?
Are you a member of the American Psychiatric Association?
 

SECTION II. Bill To Information:

If you would like your invoice to be addressed to a different recipient, please enter that information here:

Name of Company or Organization:
Attention to:
Address Line 1:
Address line 2:
Address line 3:
City:
State:
Postal Code:
Country:

SECTION III. Material to be Reproduced:

Journals:
Journal Name: 
Issue Volume and Year:
Complete Article Title:
Author of Article:
Sections, Figures, Tables, or Images to be produced (List and Specify Page numbers): 
Are you requesting use of entire article:
Books:
Book Title: 
Author:
Year Published:
Sections, Figures, Tables, or Images to be produced (List and Specify Page numbers): 
For DSM-5 Criteria Requests (List Criteria):
For DSM-5 Requests:
  • Uses needed, from the list below, must be clearly stated in the request. No blanket or derivative rights will be granted.
  • A document must be attached to the online permissions request form showing the tables as they will be reproduced in your publication. DSM material must match the source exactly, with the exception of style and format changes.
  • Each table must show the copyright notice: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.
  • Please note that for DSM-5 requests, we will only grant up to 50% of the total number of diagnostic criteria in the book.

SECTION IV. Description of Your Proposed Product:

Your Product Type:  















Name of Your product:
Author (If applicable):
Publisher or Distribution Company Name:
Number of Copies to Print:
Unit Retail Price (Please specify: one-time fee for unlimited use, subscription based fee, user-based fee, access based fee, or other type fee):
Is your product a printed publication or an electronic product or both:
In which countries are you planning to distribute your product:

Please provide a general description of your proposed product (Description is limited 1000 characters):

Please attach a document showing how our material will be displayed in your publication here (File limit is 2.5MB): Attachment:

Types of Rights You are Requesting:










SECTION V. For DSM-5 Electronic Product License Requests Electronic Health Record or software Only
This section is for requests to license Diagnostic and Statistical Manual of Mental Disorders (DSM) material in an electronic health record or other specialized medical or billing software product. Reproduction of DSM alone is not permitted. Licensed product must contain value added information.
Name of Your PName of Your Product:
General Description of your Product:
Estimated Number of Users Per Year:
Price Structure (Please specify: one-time fee for unlimited use, subscription based fee, user-based fee, access based fee, or other type fee):
List fee amount:
Type of Access and Access Restriction:
Material You Would Like to License  
 
 
 
SECTION VI: Structured Clinical Interview for DSM-5 (SCID-5) Requests
SCID Product to be licensed:


Title of the clinical trial or research study:
Start date of the clinical trial or research study:
End date of the clinical trial or research study:
Number of subjects:
Number of times the instrument will be administered to each subject:
Number of administrators/interviewers:
Number of copies that will be distributed:
Interview:
User’s Guide:
Type of use





For Clinical Trials Requests Only: Will you require specialized customization of the file for your clinical trial?
For SCID-5-CT (Clinical Trial) and SCID-5-RV (Research Version) Requests Only: Type of file that you would like to receive:

SECTION VII. Acknowledgements and Signature:

I acknowledge that submission of this request for permission or receipt of a permission fee quote does not constitute permission, and that any use of any copyrighted text or images owned by APA or APP is unauthorized unless and until I am in receipt of a signed permission letter, electronic product license agreement, or email.

I further acknowledge that my proposed use may be such that I may be required to enter into an Electronic Product License Agreement in APA or APP's sole discretion.

I further acknowledge that if any usage or administrative fees are assessed by APA or APP, the signed permission may be withheld until such fees are paid.

Please ensure that the form is completed in its entirety. Incomplete forms may delay processing of your request.

Types of uses that are not granted:
  • Use of material in mobile device applications such as ipad, itouch, iphone, android, blackberry, or any other devices
  • Use of DSM material in self-diagnosis
  • Use of DSM trademark
  • Reproduction of American Psychiatric Association and American Psychiatric Publishing logos
  • Reproduction of entire DSM content in another publication or product
        Agree         Disagree






1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901
703-907-7322 or 800-368-5777 | Fax: 703-907-1091 | appi@psych.org