PEDIATRICS/PSYCHE
Training Checklist

Name:
  (Last) (First)   (MI)
Phone Number (with area code):

Social Security Number:

Email Address

Please indicate your level of proficiency in each area by selecting the appropriate button.

PSYCHE 4 POINT RESTRAINTS Perform Independently Perform with review Limited or no experience None Selected ADMISSION OF PATIENT Perform Independently Perform with review Limited or no experience None Selected ADOLESCENT Perform Independently Perform with review Limited or no experience None Selected ADULT Perform Independently Perform with review Limited or no experience None Selected AGGRESSIVE/COMBATIVE Perform Independently Perform with review Limited or no experience None Selected ALZHEIMER'S Perform Independently Perform with review Limited or no experience None Selected ANOREXIA Perform Independently Perform with review Limited or no experience None Selected ANTISOCIAL Perform Independently Perform with review Limited or no experience None Selected CHILDREN Perform Independently Perform with review Limited or no experience None Selected DEPRESSION Perform Independently Perform with review Limited or no experience None Selected DT’S Perform Independently Perform with review Limited or no experience None Selected GROUP THERAPY Perform Independently Perform with review Limited or no experience None Selected MANIC DEPRESSIVE Perform Independently Perform with review Limited or no experience None Selected PATIENT IN SECLUSION Perform Independently Perform with review Limited or no experience None Selected SCHIZOPHRENIA Perform Independently Perform with review Limited or no experience None Selected SUBSTANCE ABUSE Perform Independently Perform with review Limited or no experience None Selected SUICIDE PRECAUTIONS Perform Independently Perform with review Limited or no experience None Selected

Authorization (Please type your name and the date.)

By submitting this application, I hereby certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

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