DR. Michael Shery, clinical psycholoGY

  2615 Three Oaks Rd, Ste. 2A, 

  Cary, Illinois 60013

www.carypsychology.com  847 275 8236 (24 Hrs);  drmike@carypsychology.com

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Doctoral degree: University of Southern California, 1975

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Counseling, Therapy and

Expert Evaluations for: 

Anxiety - Depression -Marriage -Adolescent- 

- ADHD - Alcohol -Substance Abuse -Anger - Fitness for Duty - Disability -Adoption - Weight Loss Surgery 

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Questions? Call Dr Mike NOW:

                     847 275 8236 (24 Hrs)

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Fitness for Duty Assessment

Re Subject: MS

Current Position: Anytown Hospital, Patient Care Technician (PCT)

Date: May 3, 2011

Overview of the Fitness for Duty Assessment: The assessment process consists of a series of interviews with the subject and collateral sources. It also consists in the review of psychological testing data and employment or psychological records deemed to be relevant.

It was explained to the subject that ownership of this report would reside with Anytown Hospital as would the responsibility of insuring its confidentiality in accordance with state and federal laws. The nature, parameters, ownership and extent of the evaluation and its limited confidentiality was explained to the subject and her informed consent was obtained.

Assessment Follow-Up: It was explained that if the hospital returns the subject to work, that upon a separate arrangement and the hospital's request, the evaluator may follow-up by assessing the subject's subsequent mental and work status, determining whether or not she is complying with any recommendations that may have been made and/or reviewing the effectiveness of any accommodations that have been implemented.

Data used for this Evaluation: Two interviews with the subject; results of psychological testing; review of the Incident Reporttriggering the referral; review of Dr W’s progress notes of her psychiatric treatment and an interview with her manager, Ms SS.

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Report of Incident by Subject’s Supervisor, SS, RN, BSN, leading to Referral for Fitness for Duty Assessment and Subject’s Responses to it:

Triggering events:

12/9/10- A discharge phone call was received from a patient stating “I think the nursing assistant got upset with me. I don’t think she should be around patients.

She wouldn’t talk to me. At one point she literally grabbed my arm and hurt me. I think she was just playing around, but it hurt.”

Follow up phone call to the patient 3/28 revealed the patient stating that he thought she was trying to play with him, but then she “grabbed and twisted my arm trying to put a restraint on, she frightened me and hurt me. While I resisted, she levered my arm against the railing.” There was no MD order for a restraint.

Subject Response: She said she had no memory of such an event. In fact, subject asserts that in her 14 years at the hospital, while she may have been criticized for other things, she has never been criticized for inadequacy of her patient care.

12/15/10-12/29/10: FMLA/ Subject Response: She took the time off to adjust her psychiatric medications.

12/31/10- Complaint from patient received by manager: “I overheard MS in the hallway stating that I smelled so bad that she didn’t even want to come into my room.” Manager follow up was that MS said this to another PCT in the hallway outside the patient’s room.

Pt. was crying stating that he was sorry he smelled so bad and that he hated himself. Counseled MS that we never belittle our patients, and they should never hear us as staff say anything negative about them.

Subject Response: No recall of incident

3/21/11

-PCT overheard MS stating on the phone “If I had a gun, I would kill myself. I wonder if I can get my hands on some pills so that I can die.” PCT tried to comfort MS who then swung the phone at her.

-overheard MS in the ancillary nurses station by case manager “If you think you can commit me to a psych unit, you will never see my kids again. I’m not f…ing crazy” “You treat my kids better than you treat me, so if I take them away how will you treat me” “Mom, you don’t think I’m crazy do you”

Subject Response: No memory of situation, but subject said she was probably arguing with one of her parents on the phone, with whom she has had both acute and chronic relationship problems.

-7 coworkers noticed an increase in agitation over the past 2 weeks, more defensive mannerisms, verbally abusive to coworkers. She was yelling in the nurses’ station, with MDs present, and in the hallways where patient can overhear.

Coworkers are afraid to confront her for fear of agitating her more. Staff state that they have a fear of repercussion’s by MS if they say anything to or about her.

-Staff states that she is becoming more bold with her word choices, more intense and more confrontational. She is not taking these confrontations to a private area, she is yelling in the hallway, nursing stations, and even in the patient rooms.

Subject Response: Stress resulting from increasing agitation with her controlling parents and the fact that nurses do not promptly respond to patient call lights.

-RN rounded at 8AM, pt. was confused, but OK. Nurse rounded again at 9AM, MS was sitting on the patient’s bed with the TV remote in her hand, and the patient had been posey vested to the chair. There was no order for a restraint.

When the nurse asked MS why she had restrained the patient, she started yelling at the nurse in the patient room stating that the patient was trying to get out of bed. The nurse then untied and tended to the patient while MS left the room.

Subject Response: She said her use of restraint was a safety precaution because she didn’t want the patient to fall because of her instability. She also indicated that she didn’t know she needed an MD order for such an intervention.

-I have talked with about 10 of MS’s coworkers; they do not feel that they can talk with her for fear of making her more agitated. They also state that they fear any repercussions that MS may inflict upon them. They have stated that “MS knows where I live, I’m afraid she would come to my house.”

Subject Response: She sounded astounded, at the above and stated that, these comments were “off the wall.” Consequently, when returned to work she said she does not want to return to the same floor.

Absenteeism History: Subject received the following warnings: Verbal warning 6/21/07, verbal warning 10/23/07, verbal warning 4/25/08, verbal warning 7/15/08, 1st written warning 9/25/08, 2nd written warning 2/5/09, verbal, 6/16/10, verbal 11/5/10, 1st written, 11/29/10, 1st written 1/17/11, 1st written 2/23/11, 1st written 3/8/11.

FMLA/LOA: 12/27/09 – 1/3/10; FMLA: 6/10-9/13/10; LOA: 12/15/10 – 12/29/10

LOA: 3/22/11 – present

Respectfully submitted

SS, RN, BSN

Care B Manager

(847)275-8236

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Mental Status: During my interviews with the subject she was alert, oriented to person, place, time and situation. Her levels of judgment and insight were normal, as was her ability to remember and concentrate.

She showed no signs of disordered thought processes and her manifested affect was appropriate to the content of her verbalizations. Intellectually, she appears to function in the low-average to average range.

Summary- Subject Interviews:

The subject was interviewed twice. She was punctual, dressed casually and appropriately and appeared bewildered and confused by her work suspension and the “Fit for Duty” assessment process.

She seemed particularly dependent on her husband for reassurance and support, who attended with her. She appeared taken aback and shocked by her suspension from work and the events noted in the Incident Report above; she did not recall several of the events noted.

She reports being eager and capable of returning to work, however reluctant to return to her previous unit because of embarrassment caused by her suspension.

Social History:

The client is a 45-year-old white Protestant female. She considers herself to be less devoutly religious than others of her faith. She lives in a house and has lived there for three to five years. She lives with her husband and her children.

When asked about her dietary habits, she indicated that her diet is not particularly nutritious, though she says she eats lunch and dinner. In her spare time the client enjoys domestic activities, sporting events, movies, and television.

DEVELOPMENTAL HISTORY

At the time of her delivery she had birth defects. As a child the client was neither happy nor unhappy and recalls that she was ill no more often than her peers.

As a teenager she was somewhat unhappy but remembers being healthy. Before age 18 she had a close friend with whom she could discuss nearly anything and reports having such a friend now.

The subject is not aware of childhood problems with toilet training or with learning to sit up, crawl, stand, walk, talk, feed herself, or dress herself. She does not report any childhood fears or phobias. She does not report having any difficulties with coordination, excitability, or hyperactivity before age 13.

She admits to no antisocial or daredevil behavior and she does not report a history of being sexually molested, running away from home, having suicidal preoccupations or attempting suicide as a child or teenager. She also reports no unusual eating habits as a teenager.

She did not learn about menstruation before her first period. She felt that she could discuss only certain aspects of sex with her parents and began dating before the age of 18.

She usually dated every week and usually did so with only one person at a time and remembers that her parents sometimes objected to the individuals she dated and would attempt to interfere. After the first time she had heterosexual intercourse she reportedly felt nervous and guilty. Currently, she would do anything to avoid sexual intercourse.

She did not have a homosexual experience before age 18 but did not indicate whether or not she had such an experience after that age.

FAMILY OF ORIGIN

The subject was born out of wedlock and raised by her adoptive mother and father. She reports that her adoptive mother just tolerated her and gave her insufficient time and attention.

She recalls that she could rarely talk to her adoptive mother about problems and claims that she criticized everything the subject did. She reports, however, that her adoptive mother did occasionally praise her for her accomplishments.

She reports that while her adoptive mother was reasonable in some areas, she was often very strict and always wanted to know where she was going and what she would be doing. Her adoptive mother always punished her emotionally when she misbehaved by yelling at her, taking away privileges, telling her that she was ashamed of her, putting her in "time-out," threatening her with abandonment and threatening to call the police.

Corporal punishment typically included spanking or slapping, pinching, ear or hair pulling, and shoving or pushing. The subject reports that at least once, her adoptive mother punched her, hit her with an object and attacked her with a weapon as a form of punishment.

She reports that her adoptive father also just tolerated her and gave her very little time and attention. She reports also never being able to talk to her adoptive father about problems and she claims that he criticized everything she did.

She reports her adoptive father ignoring her accomplishments and further reported that he was very strict, although reasonable in some areas, and always wanted to know where she was going and what she would be doing. Punishment always resulted when her adoptive father discovered that she had misbehaved.

To punish her psychologically, the subject reports that he would yell at her, take away privileges, tell her that he was ashamed of her, make her feel that she had hurt him, embarrass her, put her in "time-out", threaten her with abandonment or threaten to call the police.

Corporal punishment usually included spanking or slapping, ear or hair pulling, and shoving or pushing. At least once, her adoptive father hit her with an object as a form of punishment.

EDUCATIONAL HISTORY

She reports that her elementary school performance was about average, that she had problems learning to read, spell, do arithmetic, and speak correctly, and that she was placed in special classes for students with learning problems.

She admits having repeated trouble with school authorities during her elementary school years, but she was not placed in any special classes for students with behavioral problems. In general, she had mixed feelings about elementary school and describes herself as being unpopular with most schoolmates.

In high school she received mostly C's. She remembers having difficulty in high school because of problems at home and poor relationships with other students, but reports no major antisocial behaviors.

The subject describes herself as being somewhat unpopular with other students and as being generally unhappy in high school. She reports graduating from high school and trade/vocational school and attending but not finishing junior college.

Substance Abuse

The subject does not report having a problem with alcohol or using “recreational” psychoactive drugs.

MARITAL HISTORY

The client reports her primary sexual orientation to be heterosexual and she is currently married and living with her second husband. She reports being married twice, having natural children and having no problems in her relationship with her current husband.

OCCUPATIONAL HISTORY/FINANCIAL STATUS

The client is employed full-time and is paid hourly. She holds a paraprofessional position as a nurse's aid at Anytown Hospital, has had her present job for more than eight years, reports being somewhat satisfied with it and is not thinking about changing jobs at this time.

She has quit jobs in the past and reports resigning from one because of the birth of a child. Over the past year her household income has decreased somewhat but is more than sufficient to pay for basic necessities. However, she is experiencing money problems because of debt.

LEGAL HISTORY

She was granted a short-term disability claim in the past, resulting from problems with a kidney stone. She also acknowledges being treated in a psychiatric facility in the past, but denies having ever had a court-ordered mental examination.

MILITARY HISTORY

The client has never served in the United States military.

SYMPTOM SCREEN

The last physical examination the client had was within the last six months; she recalls having no problems at that time. The subject’s last dental exam was more than a year ago and she reports currently having no problems with her teeth or gums.

She reports having had surgery more than once but reports that she is currently in good health. She is far-sighted and her history also includes high blood pressure, pleurisy, frequent bronchitis, kidney stones, and bladder infection.

The subject reports recently having had a problem with being overweight and her body feeling colder than usual. She also reports recently experiencing involuntary tremors and memory lapse.

She has had a hysterectomy and has been pregnant twice. Her past pregnancies were terminated by vaginal delivery. Regarding sexual intercourse, she complains of inhibited arousal/interest.

The subject does not report having trouble with alcohol or using any unprescribed psychoactive drugs. In contradiction to her psychiatric records, no episodes of depressed mood, diminished energy, loss of appetite, sleep disturbance, or suicidal ideation lasting two or more weeks were reported.

She reports no history of suicide attempts, although records from her psychiatrist contradict that, and no periods of elated mood or hyperactivity lasting one week or more. She has experienced feelings of being controlled but she has not experienced thought broadcasting, thought insertion, thought withdrawal, auditory distortions/hallucinations or grandiose or persecutory beliefs.

She has experienced two or three anxiety or panic attacks and reports an unreasonable fear of being alone. She also admits having had unwanted, repetitive thoughts but denies having performed repetitive acts.

She has experienced a highly stressful episode triggering prolonged consequences which included intrusive memories, feelings of guilt, and avoidance of certain situations. Her current sleep pattern is characterized by waking up too early and having trouble falling back to sleep.

She also reports having used mental health services or counseling for a problem that was unrelated to alcohol or drug use.

Current Job- Nurse's Aid:

Length of Employment: 13 years

Job Description: To supplement required nursing care for patients

Performance Reviews: Generally the subject has been deemed a competent employee, and until this point, no deficits in quality of care were noted, only those involving attendance and absenteeism.

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Psychiatric History: The subject consulted Dr. PM 6 times between 10-28-10 to 3-22-11. The dates were: 10-28-10; 11-18-10; 12-14-10; 1-18-11; 2-17-11; and 3-22-11. At her initial appointment, she was diagnosed with severe recurring depression with no psychosis; Obsessive-Compulsive Disorder; and Generalized Anxiety Disorder and was prescribed Cymbalta, alprazolam and Ambien.

She reports currently taking: Zolpidem ER 12 mg; Lansorazole, 30 mgs; Metoprolol 75 mgs; alprazolam xr, .5 mgs, 2x/day; Cymbalta 60 mgs; Buspurone, 10 mgs, 2x/day

Important: At her last appointment (3-22-11) she reported having a severe blow-out with her parents and the previous Sunday had taken 3 sleeping pills to commit suicide. Dr PM recorded that the subject can become very impulsive under stress.

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Summary: SS, RN, BSN, Subject’s Manager, Interview, May 27, Friday

She indicated that the subject, generally was well-liked by the staff on the unit, but within the past “few months” she had changed to becoming increasingly angry, agitated and belligerent in front of others and more difficult to manage. She indicated that even though her peers liked and cared for her, they were afraid to make her angry for fear of retribution.

Several staff members said they wouldn’t be surprised if she went “postal.”

If deemed safe, SS said she would be pleased to have the subject back at work, but that, some of her quality of patient care issues would have to be addressed first. They have not yet addressed them because of fear the subject would not be able to cope appropriately with the criticism.

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Tests Administered and their Results:

Millon Clinical Multiaxial Inventory III (MCMI III)-

The MCMI-III profile of this woman is noted by her marked dependency needs, her depressive seeking of attention and reassurance from others, and her intense fear of separation from those who provide support. Dependency strivings have pushed her in the past to be overly compliant and to play down whatever personal strengths and attributes for independent behavior she may possess.

Recently, relationships with her adoptive parents may have become even more insecure and unreliable, possibly owing in part to permitting them to be abusive. This has resulted in increased moodiness, prolonged periods of dejection, and extended episodes of worry and anxiety.

Probably inclined to court blame and criticism, she seems to look for situations in which to place her feeling that she deserves to suffer. This subject is typically seen by friends and family as being submissive and cooperative. In recent times,

however, she has become quite self-condemning, sulky, disconsolate, and pessimistic.

She is somewhat hypochondriacal and may be disappointed in her physical appearance. She increasingly vacillates between being socially agreeable, mournful, self-abasing, passive-aggressive, and contrite. She has begun to complain of being treated unfairly, a behavior that now puts others on edge, never knowing if she will react in an agreeable or angry manner.

Although struggling to be obliging and submissive, she now anticipates disillusionment in family relationships and often creates the expected disappointment by testing and questioning the genuineness of their interest and support. Such behaviors may exasperate and eventually alienate those upon whom she depends.

Threatened by separation or disapproval, she is likely to express guilt and self-condemnation in the hope of regaining support, reassurance, and sympathy.

She has recently come to exhibit a sense of helplessness as well as anxious and depressive moods.

Fearing that others may grow weary of her behavior, she may alternate between voicing self-deprecation and melancholy, and being petulant and irritable. An increasing inability to regulate her emotional controls may add to her feeling of being misunderstood and may further contribute to her erratic moodiness and state of persistent self-criticism and dejection.

Personality Configuration

Most notable is her feeling of isolation and undesirability, further complicated by her tendency to devalue her achievements, which together result in an intensified sense of having been socially derogated and isolated. She tends to be excessively introspective and self-conscious, seeing herself as markedly and negatively different from others, unsure of her identity and self-worth.

The alienation she feels from others is thus paralleled by a feeling of alienation from herself. Also salient is the presence of anxiety-ridden and painful memories that are easily reactivated by minor social stressors.

Further complicating this picture is the fact that she has few avenues for psychic gratification, tension relief, or conflict resolution. She feels trapped in the worst of her inner and outer worlds, seeking to avoid both the distress that interpersonal relations bring and the emptiness and wounds that inhere within.

Also worthy of attention is her tendency to see things in their bleakest form, to give the gloomiest interpretation to events, and to be invariably pessimistic, expecting the worst to happen. She may try to fight back depressive feelings and thoughts by consciously diverting her ideas and preoccupations away from depressive moods.

For the most part, unfortunately, these attempts are replaced by ruminations that are newer and troublesome as well. She tends to reactivate and then brood over minor incidents from the past and is likely to believe that her present negative state is irreversible and that any attitude other than pessimism or gloom is merely illusory.

Also noteworthy is her characterological inclination to be mournful, joyless, tearful, and morose, an emotional disposition that is intensified by her tendency to be worrisome, pessimistic, and guilt-ridden. Her interest in life is diminished, and she appears to have little pre-disposition for joy and closeness.

Although she may go through the motions of relating to others, she often does so with little enthusiasm. Her temperamentally based inertia and sadness may undermine whatever capacity she may have to enjoy life and enrich her relationships.

Also noteworthy is her inclination to subordinate her own wishes to a stronger and (she hopes) nurturing person, resulting in the habit of being conciliatory, deferential, and self-sacrificing, particularly with her husband. She probably believes that it is best to leave some matters to him and to some other significant figures and to place her fate with them.

In her view, it is likely that she perceives others to be much better equipped to shoulder responsibility, to navigate the intricacies of a complex world, and to discover and achieve the satisfaction to be found in the competitions of life.

AXIS I: CLINICAL SYNDROMES

Interwoven with this subject's fretful and melancholic feelings are clear signs of a major depression overlying a characterologic mix of dysthymic features. Notable among these features are a diminished capacity for pleasure, preoccupation with lessened energy and adequacy, pessimism, a loss of confidence, feelings of worthlessness, resentment, and fears that she may vent her anger and thereby lose the little security she possesses.

Unsure of the fidelity and dependability of some of those on whom she has previously leaned, but ambivalent about currently needing them, she not only attempts to restrain her anger, albeit often unsuccessfully, but sometimes turns it inward, producing judgments of self-derision and guilt. Her low self-esteem and fear of loss induce her to feel increasingly hopeless and even, at times, to entertain thoughts of suicide.

Consistent with her pervasive discontent and sadness, this subject reports suffering from a variety of symptoms that constitute an anxiety disorder. In addition to palpitations, distractibility, jittery feelings, and restlessness at one moment and exhaustion the next, she may experience presentiments of tragic outcomes as well as periodic panic attacks and agoraphobia.

Expecting the worst to happen, she not only looks for confirmation but also may precipitate events that generate self-defeating stressors that further intensify her anxieties.

In dreams or nightmares, she may become terrified, exhibiting a number of symptoms of intense anxiety. Other signs of distress might include difficulty falling asleep, outbursts of anger, panic attacks, hypervigilance, exaggerated startle response, or a subjective sense of numbing and detachment.

NOTEWORTHY RESPONSES

The subject answered the following statements in the direction noted in parentheses. These items suggest specific problem areas to be noted.

Health Preoccupation

1. Lately, my strength seems to be draining out of me, even in the morning. (True)

4. I feel weak and tired much of the time. (True)

55. In recent weeks I feel worn out for no special reason. (True)

75. Lately, I've been sweating a great deal and feel very tense. (True)

130. I don't have the energy to concentrate on my everyday responsibilities anymore. (True)

149. I feel shaky and have difficulty falling asleep because painful memories of a past event keep running through my mind. (True)

Interpersonal Alienation

10. What few feelings I seem to have I rarely show to the outside world. (True)

18. I'm afraid to get really close to another person because it may end up with my being ridiculed or shamed. (True)

48. A long time ago, I decided it's best to have little to do with people. (True)

63. Many people have been spying into my private life for years. (True)

69. I avoid most social situations because I expect people to criticize or reject me. (True)

99. In social groups I am almost always very self-conscious and tense. (True)

161. I seem to create situations with others in which I get hurt or feel rejected. (True)

167. I take great care to keep my life a private matter so no one can take advantage of me. (True)

174. Although I'm afraid to make friendships, I wish I had more than I do. (True)

Emotional Dyscontrol

22. I'm a very erratic person, changing my mind and feelings all the time. (True)

34. Lately, I have gone all to pieces. (True)

83. My moods seem to change a great deal from one day to the next. (True)

116. I have had to be really rough with some people to keep them in line. (True)

124. When I'm alone and away from home, I often begin to feel tense and panicky. (True)

Self-Destructive Potential

24. I began to feel like a failure some years ago. (True)

44. I feel terribly depressed and sad much of the time now. (True)

128. I feel deeply depressed for no reason I can figure out. (True)

142. I frequently feel there's nothing inside me, like I'm empty and hollow. (True)

150. Looking ahead as each day begins makes me feel terribly depressed. (True)

151. I've never been able to shake the feeling that I'm worthless to others. (True)

154. I have tried to commit suicide. (True)

171. I have given serious thought recently to doing away with myself. (True)

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The Aggression Questionnaire (AQ):

The Inconsistent Responding Index (INC) does not indicate an unusual amount of inconsistency in her responses, meaning that she was attentive when taking the test.

The Physical Aggression Score (PHY) suggesting that she is likely to have a relatively strong ability to control her physically aggressive impulses.

The Verbal Aggression Score (VER) suggests she may become increasingly argumentative when frustrated or stressed, which is consistent with her current diagnosis of anxiety disorder. Learning behavioral stress-reduction skills might be helpful.

The Anger Score (ANG) suggests that she is likely to experience irritability and frustration that she may feel unable to control. Again, she may benefit from stress reduction or anger management training.

The Hostility Score (HOS) for this subject is high. A strong tendency to mistrust others is suggested and she may find it difficult to empathize with the thoughts and feelings of others. She should be helped to cognitively re-structure her view of others and taught to empathize.

In general, these scores are consistent with her psychiatric diagnoses and would suggest increased, focused therapeutic measures are indicated to moderate the hyper-arousal sensations she experiences.

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The Novaco Anger Scale and Provocation Inventory (NAS-PI)

The following sample of answers might constitute areas where her self-improvement efforts should focus:

The subject shows a moderate tendency towards self-justification. She answered “sometimes true” to the following:

-I get angry because I have good reason to get angry

-The more someone bothers me the angrier I will get.

She also shows a moderate tendency towards rumination, hostility and suspicion. She answered “sometimes true” to the following:

Once something gets me angry I keep thinking about it.

When someone makes me angry, I think about getting even.

If I don’t like someone., it doesn’t bother me to hurt their feelings.

People act like they are being honest when they really have something to hide.

When I get angry I feel like smashing things.

She answered “always true” to:

When I get mad at someone I give them the silent treatment.

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Diagnostic Impression:

Axis I: Clinical Syndrome

The major complaints and behaviors of the patient parallel the following Axis I diagnoses, listed in order of their clinical significance and salience:

296.33 Major Depression (recurrent, severe, without psychotic features)

309.24 Adjustment Disorder with Anxiety

AXIS II: Personality configuration composed of the following:

301.60 Dependent Personality Disorder;

301.82 Avoidant Personality Disorder with Depressive Personality Traits and Negativistic (Passive-Aggressive) Personality Traits

Conclusion: The subject is a sincere worker whose ability to cope with situational stressors, particularly, involving serious conflicts with her parents, has been ineffective at work because of seriously compromised anger and stress management skills.

Fitness to Work and Recommendations:

Inability to effectively manage her situational stressors, angry outbursts and frustration could affect the subject's ability to perform the essential functions of her job safely.

Is any treatment or further evaluation needed? I recommend that the hospital allow her to return to work subject to the following: That she participate in therapy twice a month for a three month period, with a psychologist or other mental health professional who would treat her specifically to enhance her ability to effectively manage stress, anger and frustration in the workplace.

Such a professional would be retained by the hospital and have unlimited access to the assessments of the subject’s supervisors and managers to monitor her success. At the end of the three month period her status would be re-evaluated, which could lead to her return to ordinary work status, dismissal, continuation in treatment or some other recommendation or accommodation.

Respectfully Submitted,_________________________;_____________

Dr. Michael Shery, Psychologist; 71-1937 Date

Diplomate: International Academy of Behavioral Medicine, Counseling and Psychotherapy

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