Psychologial and Emotional Health

Section 5 – Psychological and Emotional Health
The U.S. government recognizes the critical importance of mental health and advocates proactive management of mental health conditions to support
the wellness and recovery of Federal employees and others. Every day individuals with mental health conditions carry out their duties without
presenting a security risk. While most individuals with mental health conditions do not present security risks, there may be times when such a
condition can affect a person’s eligibility for a security clearance.
Individuals experience a range of reactions to traumatic events. For example, the death of a loved one, divorce, major injury, service in a military
combat environment, sexual assault, domestic violence, or other difficult work-related, family, personal, or medical issues may lead to grief,
depression, or other responses. The government recognizes that mental health counseling and treatment may provide important support for those who
have experienced such events, as well as for those with other mental health conditions. Nothing in this questionnaire is intended to discourage those
who might benefit from such treatment from seeking it.
Mental health treatment and counseling, in and of itself, is not a reason to revoke or deny eligibility for access to classified information or for
holding a sensitive position, suitability or fitness to obtain or retain Federal or contract employment, or eligibility for physical or logical access to
federally controlled facilities or information systems. Seeking or receiving mental health care for personal wellness and recovery may contribute
favorably to decisions about your eligibility.
5A) Has a court or administrative agency EVER issued an order declaring you mentally
YES
NO (Required to validate)
incompetent?
You responded ‘Yes’ to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.
Provide the date this occurred.
Date (Month/Year) (Estimated)
Provide the name of the court or administrative agency that declared you mentally
Name (Free Text)
Branch
incompetent.
If Yes to
Provide the address of the court or administrative agency.
Being
Street address and city
State and Zip Code or Country
Declared
Was this matter appealed to a higher court or administrative agency?
YES
NO (Required to validate)
Incompetent
You responded ‘Yes’ to appealed to a higher court or administrative agency.
Branch
(Multiple
If Yes to Appealed to
Provide the name of the court or administrative agency.
Name (Free Text)
Entries
a Higher Court or
Provide the address of the court or administrative agency
Allowed)
Administrative
Street address and city
State and Zip Code or Country
Agency. (Multiple
Provide the final disposition.
Disposition (Free Text)
Entries Allowed)
Do you have an additional instance where this matter was appealed to a
YES
NO
higher court or administrative agency?
(Yes adds another entry)
(Required to
validate)
Do you have an additional instance where a court or administrative agency
YES
NO
EVER issued an order declaring you mentally incompetent?
(Yes adds another entry)
(Required to
validate)
5B) Has a court or administrative agency EVER ordered you to consult with a mental health professional (for example, a
YES NO (Required
psychiatrist, psychologist, licensed clinical social worker, etc.)? (An order to a military member by a superior officer is
to validate)
not within the scope of this question, and therefore would not require an affirmative response. An order by a military court
would be within the scope of the question and would require an affirmative response.)
You responded ‘Yes’ to having a court or administrative agency EVER ordered you to consult with a mental health professional.
Branch
If Yes to
Provide the date this occurred.
Date (Month/Year) (Estimated)
Court or
Provide the name of the court or administrative agency that declared you mentally
Name (Free Text)
Administrati
incompetent.
ve agency
Provide the address of the court or administrative agency.
EVER
Street address and city
State and Zip Code or Country
ordered you
Provide the final disposition
Disposition (Free Text)
to consult
Was this matter appealed to a higher court or administrative agency?
YES
NO (Required to validate)
with a mental Branch
You responded ‘Yes’ to appealed to a higher court or administrative agency.
health
If Yes to Appealed
Provide the name of the court or administrative agency.
Name (Free Text)
professional
to a Higher Court or Provide the address of the court or administrative agency
(Multiple
Administrative
Street address and city
State and Zip Code or Country
Entries
Agency. (Multiple Provide the final disposition.
Disposition (Free Text)
Allowed)
Entries Allowed)
Do you have an additional instance where this matter was appealed to a
YES
NO
higher court or administrative agency?
(Yes adds another
(Required to validate)
entry)
Do you have an additional instance where a court or administrative agency
YES
NO
EVER ordered you to consult with a mental health professional (for
(Yes adds another
(Required to validate)
example, a psychiatrist, psychologist, licensed clinical social worker, etc.)?
entry)
(An order to a military member by a superior officer is not within the scope
of this question, and therefore would not require an affirmative response. An
order by a military court would be within the scope of the question and
would require an affirmative response.)
5C) Have you EVER been hospitalized for a mental health condition?
YES
NO (Required to validate)
You responded ‘Yes’ to EVER been hospitalized for a mental health condition.
Branch
If Yes to
Was the admission voluntary or involuntary?
Voluntary (Provide explanation)
Explanation

EVER been
hospitalized
for a mental
health
condition
(Multiple
Entries
Allowed)

Provide the dates of treatment.

Involuntary (Provide explanation)
From Date (Month/Year) (Estimated)

Provide the name and address of the facility where treatment was provided.
Provide the address of the facility where treatment was provided.
Street address and city
Do you have an additional instance where you have EVER been hospitalized for a
mental health condition?

Explanation
To Date
(Month/Year)
(Estimated/Present)

Name (Free Text)

State and Zip Code or Country
YES (Yes
NO (Required to validate)
adds another
entry)
The following question asks whether you have been diagnosed with a specified mental health condition that may, particularly if untreated, impact
your judgment, reliability, or trustworthiness. If you answer in the affirmative, we will seek additional information about the seriousness and
symptoms of the condition, as well as any applicable course of treatment. It is important to note that any such diagnosis, in and of itself, is not a
reason to revoke or deny eligibility/or access to classified information or for holding a sensitive position, suitability or fitness to obtain or retain
Federal or contract employment, or eligibility for physical or logical access to federally controlled facilities or information systems.
5D) Have you EVER been diagnosed by a physician or other health professional (for example, a
YES
NO (Required to
psychiatrist, psychologist, licensed clinical social worker, or nurse practitioner) with psychotic disorder,
validate)
schizophrenia, schizoaffective disorder, delusional disorder, bipolar mood disorder, borderline
personality disorder, or antisocial personality disorder?
You responded ‘Yes’ to having EVER been diagnosed by a physician or other health professional.
Identify the diagnosis or health condition.
Diagnosis or health condition (Free Text)
Provide the dates of diagnosis.
From Date
To Date
Branch
(Month/Year)
(Month/Year)
If Yes to
(Estimated)
(Estimated/Present)
EVER been
Provide the name, address, and telephone number of the health care professional
Name
Telephone Number
diagnosed by
who diagnosed you, or is currently treating you for such diagnosis, or with
(Free Text)
(Free Text)
a physician
whom you have discussed such condition.
or other
Provide the address of the health care professional who diagnosed you, or is
Street address and city
State and Zip Code
health
currently treating you for such diagnosis, or with whom you have discussed such
or Country
professional
condition.
(Multiple
Provide the name, address, and telephone number of any
Name or same as
Telephone Number
Entries
agency/organization/facility
above (Free Text)
or same as above
Allowed)
where counseling/treatment was provided
(Free Text)
Provide the address of any agency/organization/facility
Street address and city
State and Zip Code
where counseling/treatment was provided
or same as above
or Country or same
as above
Was the counseling/treatment effective in managing your symptoms? Provide
YES
NO
Explanation
explanation.
(Provide
(Free Text)
explanation)
(Required to
validate)
Do you have an additional instance where you EVER had been diagnosed by a
YES (Yes adds
NO (Required to
physician or other health professional (for example, a psychiatrist, psychologist,
another entry)
validate)
licensed clinical social worker, or nurse practitioner) with psychotic disorder,
schizophrenia, schizoaffective disorder, delusional disorder, bipolar mood
disorder, borderline personality disorder, or antisocial personality disorder?
In the last seven years, have there been any occasions when you did not consult
YES
NO (Required to
with a medical professional before altering or discontinuing, or failing to start a
validate)
prescribed course of treatment for any of the listed diagnoses?
Are you currently in treatment?
YES
NO (Required to validate)
Branch
If Yes to
Name
Telephone Number (Free
currently in
Provide the name, address, and telephone number of the
(Free Text)
Text)
treatment.
healthcare professional providing such treatment.
(Multiple
Entries
Provide the address of the healthcare professional providing
Street address and city
State and Zip Code or
Allowed)
such treatment.
Country
Do you have an additional instance where you are currently in
YES (Yes adds
NO (Required to validate)
treatment?
another entry)
5E) Do you have a mental health or other health condition that substantially adversely affects
YES
NO (Required to
your judgment, reliability, or trustworthiness even if you are not experiencing such symptoms
validate)
today?
Note: If your judgment, reliability, or trustworthiness is not substantially adversely affected by a
mental health or other condition, then you should answer "no" even if you have a mental health or
other condition requiring treatment. For example, if you are in need of emotional or mental health
counseling as a result of service as a first responder, service in a military combat environment,
having been sexually assaulted or a victim of domestic violence, or marital issues, but your
judgment, reliability or trustworthiness is not substantially adversely affected, then answer "no."

Branch
If Yes to
having a
mental health
condition
that
adversely
affects your
judgment,
reliability, or
trustworthine
ss.
(Multiple
Entries
Allowed)

You responded ‘Yes’ to having a mental health condition that substantially adversely affects your judgment, reliability, or
trustworthiness.
Did you ever receive or are you currently receiving counseling
YES
NO
Explanation
I decline to
or treatment for that condition? (You may choose not to answer
(Provide
(Free Text)
answer (Required
this question. However, such consultation or treatment will not
explanation)
to validate)
disqualify you and is considered to be a positive action.)
(Required to
validate)
Provide the following about your counseling or treatment.
Provide the dates of counseling
To Date (Month/Year)
To Date (Month/Year)
Branch
or treatment.
(Estimated)
(Estimated/Present)
If Yes to you ever
Provide the name, address, and
Name
Telephone Number (Free Text)
received or are you
telephone number of the health
(Free Text)
currently receiving
care professional.
counseling or treatment
Provide the address of the health
Street address and city
State and Zip Code or Country
for that condition.
care professional.
(Multiple Entries
Provide the name, address, and
Name or same as above
Telephone Number or same as
Allowed)
telephone number of the
(Free Text)
above (Free Text)
agency/organization/facility
where counseling/treatment was
provided
Provide the address of the
Street address and city or same
State and Zip Code or Country
agency/organization/facility
as above
or same as above
where counseling/treatment was
provided
Do you have an additional instance where you ever received
YES (Yes adds another entry)
NO
I decline to
or are you currently receiving counseling or treatment for that
(Required
answer
condition? (You may choose not to answer this question.
to
(Required to
However, such consultation or treatment will not disqualify
validate)
validate)
you and is considered to be a positive action.)
Have you ever chosen not to follow a prescribed course of
YES
Explanation (Free
NO (Required to validate)
treatment for any of these conditions?
Text)