Statement Of Health Form - Dphhs Home (Page 2 of 2) in pdf

Statement Of Health Form - Dphhs Home Page 2

[

] Yes

[

] No Are you currently diagnosed, receiving therapy or medication for a mental health problem which might affect

your ability to provide care?



If “Yes,” Please Explain. (There is additional room on the next page.)

[

] Yes

[

] No Have you received counseling or treatment related to chemical dependency on drugs or alcohol within the past

three years?



If “Yes,” Please Explain. (You may use additional paper if needed.)

[

] Yes

[

] No

Have you ever been addicted to drugs and/or alcohol or been treated for drugs and/or alcohol abuse within the

past three years?



If “Yes,” Please Explain. (You may use additional paper if needed.)

Additional Comments:

PLEASE READ, THEN SIGN AND DATE:

I certify that I have reviewed the foregoing information supplied by me and that it is true, accurate and complete to the best of my knowledge.

I further certify that I fully understand that any misstatement on my part in completing this health statement is grounds for denying my

application or for revoking my registration/license should one have been issued to me on the basis of the statements I have made herein. I

understand this information is confidential and is to be used only by the Department of Public Health and Human Services for the

administration of the child care licensure program. I hereby consent to the use of this information for such purposes.

SIGNATURE: ______________________________________________________

DATE:__________________________

Statement Of Health Form - Dphhs Home Page 2