1. SOCIAL SECURITY NUMBER: ___________________
2. BIRTH DATE: __________________
3. PRINT FULL NAME EXACTLY AS IT APPEARS ON YOUR LICENSE.
Last: ______________________________
First: ______________________________
Middle: ______________________________
4. ADDRESS:
Care of: ______________________________________
Street: ______________________________________
______________________________________
City: ______________________________________
State: ___________ Zip Code: ______________
5. TELEPHONE:
Home: (_____) ___________________
Work: (_____) ___________________
6. List the profession(s) in which you are licensed in New York State, and the corresponding license number(s).
________________________________________
________________________________________
List all other states and countries in which you are licensed or registered to practice:
___________________________________________________________________________
7. How did you learn about the professional assistance program?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
8. Describe the events that led to your application to PAP:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
9. a. Have you had treatment in the past for alcohol and/or substance abuse?
YES NO (circle one)
b. Are you currently in treatment for alcoholism or other substance abuse?
YES NO (circle one)
Describe the treatment program(s) you have completed, are enrolled in, or plan to enroll in, starting with most recent.
Date Name of Agency Length of stay
_______________ ___________________________________ ___________________
_______________ ___________________________________ ___________________
_______________ ___________________________________ ___________________
_______________ ___________________________________ ___________________
10. Are you involved in any Twelve Step Program (AA/NA), etc? YES NO (circle one)
11. Do you have a sponsor? YES NO (circle one)
12. Are you currently being monitored via toxicology screens? YES NO (circle one)
If "Yes", do they test for alcohol? __________________________________________
13. Are you under any psychiatric care? YES NO (circle one)
If "Yes", please explain. ____________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
14. Are you taking any psychotropic medications? YES NO (circle one)
If "Yes", list the medications. ______________________________________________
15. Are there any current restrictions on your license in this state or in any other state or country? YES NO (circle one)
If "Yes", please explain. ___________________________________________________
16. Are you or have you every been subject to any investigation or prosecution by the Office of Professional Discipline? YES NO (circle one)
If "Yes", please explain. ___________________________________________________
17. Have you ever been charged with or
convicted of a crime (felony or misdemeanor) in any state or
country? YES NO (circle one)
If "Yes", please explain, and indicate the state or
country where it took place or is pending:
__________________________________________________________________________
18. Describe your present professional practice, including place and address of employment, responsibility, etc.
__________________________________________________________________________
__________________________________________________________________________
19. AFFIDAVIT
I affirm that no patient or client harm has resulted from my impairment. I hereby consent to the investigation by the Department of any question of eligibility arising from a question of patient or client harm. Under penalties of perjury, I declare and affirm that the statements made in this application, including accompanying statements and documents, are true, complete, and correct. I understand that any false or misleading information in, or in connection with, my application may lead to disciplinary charges and discharge from the Professional Assistance Program.
Signature: _________________________________________ Date: ____/____/_____
Attach consent forms to the application and mail to:
