Employment Inquiry

Employment Inquiry for Mental Health Providers

Date:	_____________
TO:	________________________
	________________________
	________________________
	________________________

________________________________, Social Security number _________________, has applied for a position as a mental health services provider for the University of Texas Health Science Center at Houston (UTHealth).

As required by the provisions of Chapter 81 of the Texas Civil Practice and Remedies Code, please respond to the following questions. Be advised that Texas law imposes liability on employers and former employers who know of occurrences of the conduct described and fail to disclose the information after receiving a specific request for information from a current or prospective employer.

Did the individual named on this form serve as a mental health services provider* at your institution?

( ) NO	( ) YES	Date of employment __________________ to __________________
		Title __________________________________________________

If yes, were there any allegations that the above named individual:

a. had sexual contact with a patient or former patient ( ) YES ( ) NO b. sexually exploited a patient or former patient ( ) YES ( ) NO c. therapeutically deceived a patient or former patient ( ) YES ( ) NO

Please return the completed form to the address listed below:

The University of Texas Health Science Center at Houston (UTHealth) Human Resources, Suite 150 7000 Fannin Houston, Texas 77030-5401

Thank you for your prompt response.

Signature of Respondent ______________________________
Name (please print) ______________________________	Title ________________________________
Telephone Number ______________________________

*A mental health services provider is a person who provides or purports to provide mental health services, which are assessment, diagnosis, treatment, or counseling in a professional relationship to assist an individual or group in alleviating mental or emotional illness, symptoms, condition, or disorders, including alcohol or drug addiction; understanding conscious or subconscious motivations, resolving emotional, attitudinal, or relationship conflicts, or modifying feelings, attitudes, or behaviors that interfere with effective emotional, social, or intellectual functioning.

Updated 12/02