Laserfiche WebLink
M7. Have you ever had any professional contact with a mental health provider, for a reason <br /> other than pre-employment evaluations?(NOTE:IF YOU ANSWERED"YES"TO ANY OF <br /> QUESTIONS M2-M6 ABOVE,YOU SHOULD ANSWER YES TO THIS QUESTION ALSO.) <br /> a. No <br /> b. Yes, 1-2 times <br /> c. Yes,3-5 times <br /> d. Yes, 6-10 times � <br /> e. Yes, 11-20 times <br /> f. Yes, more than 20 times <br /> IF YOU ANSWERED"NO",SKIP TO QUESTION M10. <br /> IF YOU ANSWERED"YES",CONTINUE WITH QUESTION M8. <br /> M8. Did any professional contact that you had with a mental health provider result in a <br /> formal written report? <br /> a. No <br /> b. Yes <br /> M9. Did any professional contact that you had with a mental health provider result in a <br /> diagnosis(such as"adjustment disorder"or"major depression")? <br /> a. No <br /> b. Yes <br /> M10. Have you ever had emotional or psychological problems that resulted in any of the following <br /> consequences? (MARK ALL THAT APPLY) <br /> a. Some limitation, at the time of the problems,of a major life activity such as walking, <br /> talking, sleeping, caring for yourself, learning, concentrating, interacting with others, or <br /> performing manual tasks? <br /> b. Some impairment, at the time of the problems, of your work function? <br /> c. Some limitation,currently, of a major life activity such as walking, talking, sleeping, <br /> caring for yourself, learning, concentrating, interacting with others, or performing manual <br /> tasks? <br /> d. Some impairment, currently, of your work function? <br /> e. Receiving a prescription for anti-depressants or mood elevators (such as Prozac or <br /> amitriptyline), or mood stabilizers(such as lithium or tegretol)? <br /> f. Receiving a prescription for tranquilizers or anti-anxiety drugs (such as barbiturates, <br /> valium, librium, or stelazine)? <br /> g. None of the above <br /> • <br /> PSS/LE PS PLLC 97 <br />