Public Psychological Services 10/29/2019

SECTION 3B. LEGAL HISTORY: MISCELLANEOUS HAVE YOU EVER BEEN NAMED IN ANY LEGAL RESTRAINING ORDER (BY SPOUSE/ROMANTIC PARTNER, EMPLOYER, NEIGHBOR, ETC.)? No, NEVER YES, ONE TIME YES, MORE THAN ONCE IF YES, LIST DATE(S): REASON: NO YES HAVE YOU EVER BEEN INVOLVED IN A DOMESTIC VIOLENCE INCIDENT? If Yes: DETAILS: HAVE YOU EVER COMMITTED, OR BEEN ACCUSED OF COMMITTING THREATS OF PHYSICAL HARM; STALKING; OR ACTUAL PHYSICAL HARM,TOWARD ANYONE AT ANY TIME? No, NEVER YES, ONE TIME YES, MORE THAN ONCE IF YES, LIST DATE(S): REASON: NO YES HAVE YOU EVER BEEN ACCUSED OF, OR COMMITTED, "DATE RAPE"? (SEXUAL CONTACT WITH SOMEONE WHO RESISTED,WHETHER OR NOT THEY LATER COMPLAINED TO AUTHORITIES) IF YES: YEAR: DETAILS: NO YES HAVE YOU EVER ENGAGED IN SEXUAL ACTS WHILE AT WORK(INCLUDING, BUT NOT LIMITED TO INTERCOURSE, ORAL SEX, MASTURBATION)? If Yes: Year(s) How Often? Any Complaints/Discipline regarding this behavior? NO YES HAVE YOU EVER ENGAGED IN SEXUAL ACTS WITH AN ANIMAL? If Yes: Year(s) Details NO YES HAVE YOU EVER LOOKED AT CHILD PORNOGRAPHY(GIRLS OR BOYS UNDER THE AGE OF 18) ON THE INTERNET;-OR IN MAGAZINES, MOVIES OR OTHER MEDIA? If Yes: Year(s) How Often? NO YES HAVE YOU EVER HAD ANY CONTACT WITH A CRIMINAL ENTERPRISE(FOR EXAMPLE, ORGANIZED CRIME)? NO YES HAVE YOU EVER BEEN A MEMBER OF, OR AFFILIATED WITH,A STREET GANG AS A JUVENILE OR AS AN ADULT? NO YES HAVE YOU EVER CONTACTED AN INMATE OF NYS DOCS BY PHONE, MAIL, OR AS A VISITOR? SECTION 4.A. REHABILITATION/TREATMENT HISTORY NO YES HAVE YOU EVER BEEN REHABILITATED OR OTHERWISE TREATED FOR ALCOHOL RELATED PROBLEMS. INCLUDE IN-PATIENT, OUT PATIENT,ALCOHOLICS ANONYMOUS, ETC. CONTACTS BOTH VOLUNTARY AND MANDATED. NO YES HAVE YOU EVER BEEN REHABILITATED OR OTHERWISE TREATED FOR PROBLEMS WITH DRUGS OTHER THAN ALCOHOL. INCLUDE IN-PATIENT, OUT PATIENT, 12 STEP PROGRAMS, ETC. BOTH VOLUNTARY AND MANDATED. PSS/CEPS PLLCc) Law Enforcement Psychological Services, Inc. (408) 356-9696 52