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L4. Have you ever failed to make child support payments that you were legally required to <br /> make? <br /> a. No <br /> b. Yes <br /> L5. Do you have any children under age 18 that do not live with you,and that you are not <br /> supporting through a legally monitored program (e.g., through the courts or welfare )? For <br /> example, do you have children that you do not support, or that you support only through an <br /> agreement with the caretaker parent? <br /> a. No. I do not have any biological children under age 18, or any children who do not live <br /> with me. <br /> b. No. I have biological children under age 18 who do not live with me, but I support them <br /> through a payment program monitored by the courts or any other government agency. <br /> c. Yes. I have biological children under age 18 who do not live with me, that I do not <br /> support, or that I support only by agreement with the caretaker parent. <br /> L6. Have you or your spouse, or any custodian of your children ever used physical discipline <br /> that produced red marks,welts, or bruises on your children? <br /> a. No <br /> b. Yes, 1 time <br /> • <br /> c. Yes, 2 times <br /> d. Yes, 3 or more times <br /> L7. Have you or your spouse or any custodian of your children ever been referred to Child <br /> Protective Services? <br /> a. No <br /> b. Yes, 1 time • <br /> c. Yes, 2 times <br /> d. Yes, 3 or more times <br /> PSYCHOLOGICAL TREATMENT AND EVALUATION HISTORY <br /> Note: Your answers to the following general information questions may be verified by checks of <br /> records kept by police agencies, courts, and social service agencies, and by interviews with <br /> persons acquainted with you. If you deliberately give false or misleading answers, you may be <br /> disqualified. <br /> A history of psychological counseling does not automatically result in disqualification of <br /> an application for a public safety position, and, indeed, is usually not a concern. <br /> Ml. Have you ever voluntarily consulted with a psychologist, psychiatrist, or family counselor for <br /> any reason? (Do NOT COUNT PRE-EMPLOYMENT PSYCHOLOGICAL EVALUATIONS.) <br /> a. No <br /> b. Yes, with one therapist/counselor <br /> c. Yes,with two different therapists/counselors <br /> d. Yes, with three or more different therapists/counselors <br /> PSS/LEPS PLLC 95 <br />