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Print last name, first initial <br /> SECTION 4.B. PSYCHOLOGICAL TREATMENT AND EVALUATION HISTORY <br /> You should be aware that a history of psychological counseling is usually not a concern and it <br /> does not automatically result in disqualification. <br /> NO YES HAVE YOU EVER CONTACTED A MENTAL HEALTH PROVIDER, SUCH AS A <br /> PSYCHOLOGIST,PSYCHIATRIST, OR FAMILY COUNSELOR FOR ANY REASON?(DO NOT <br /> INCLUDE OTHER PRE-EMPLOYMENT EVALUATIONS.) <br /> IF YES, HOW MANY DIFFERENT MENTAL HEALTH PROFESSIONALS HAVE YOU SEEN IN YOUR LIFE? <br /> NO YES DOES NOT APPLY IF YOU SERVED IN THE MILITARY DID YOU EVER CONTACT A <br /> MENTAL HEALTH PROVIDER, SUCH AS A PSYCHOLOGIST,PSYCHIATRIST, OR COUNSELOR <br /> FOR ANY REASON? <br /> NO YES DOES NOT APPLY IF YOU SERVED IN THE MILITARY ARE YOU CURRENTLY RECEIVING <br /> COMPENSATION FROM THE VETERAN'S ADMINISTRATION FOR A PSYCHOLOGICAL <br /> DISABILITY SUCH AS, PTSD? <br /> IF YES, WHAT PERCENT DISABILITY CLASSIFICATION DO YOU HAVE? <br /> NO YES DOES NOT APPLY IF YOU SERVED IN THE MILITARY WAS YOUR DISCHARGE FROM <br /> THE SERVICE RELATED IN ANY WAY TO PSYCHOLOGICAL ISSUES? <br /> IF YES, SPECIFY: <br /> NO YES AS A CHILD OR AN ADULT WERE YOU EVER EVALUATED, TREATED, OR PRESCRIBED <br /> MEDICATION FOR ATTENTION DEFICIT DISORDER(ADD), DYSLEXIA OR LEARNING <br /> DISABILITIES BY ANY MENTAL HEALTH OR OTHER MEDICAL PROFESSIONALS? <br /> IF YES, LIST DATE(S): REASON: <br /> NO YES HAVE YOU BEEN HOSPITALIZED FOR PSYCHIATRIC OR PSYCHOLOGICAL <br /> REASONS AT ANY TIME IN YOUR LIFE? IF YES, PLEASE PROVIDE DETAILS BELOW___ <br /> HOSPITAL YEAR <br /> NO YES WERE YOU EVER REQUIRED(BY THE COURTS, YOUR EMPLOYER, OR OTHER <br /> REASON)TO BE EVALUATED AND/OR TREATED BY A MENTAL HEALTH PROFESSIONAL <br /> BECAUSE OF YOUR BEHAVIOR, OR ALLEGED BEHAVIOR? <br /> IF YES, PLEASE PROVIDE THE FOLLOWING INFORMATION: <br /> YEAR REASON FOR EVALUATION/TREATMENT <br /> IF YOU WERE SEEN BY ONE OR MORE PSYCHOLOGISTS OR OTHER MENTAL HEALTH PROVIDERS, REPORT <br /> THE YEAR, NUMBER OF SESSIONS,AND REASON FOR EACH CONTACT IN THE SPACES BELOW. [USE THE <br /> BACK OF THIS FORM TO LIST ADDITIONAL COUNSELING CONTACTS.] <br /> YEAR APPROXIMATE#OF SESSIONS <br /> REASON <br /> YEAR APPROXIMATE#OF SESSIONS <br /> REASON <br /> PSYCHOLOGIST: THERAPY RELEASE FORM(S)GIVEN TO APPLICANT? YES (# ) NO <br /> (c) Law Enforcement Psychological Services, Inc. (408) 356-9696 <br /> Rev Date April 2009 Post_PsyQ Supp NY.doc <br /> PSS/LEPS PLLC 53 <br />