MS604.20—Sexual Exploitation Background Check
A previous employee of yours has been offered a position for employment with People Incorporated providing direct care services to vulnerable children and/or adults.
People Incorporated is complying with Minnesota Statute 604.20 entitled, Action for Sexual Exploitation; Psychotherapists. The statute defines psychotherapist as “a physician, psychologist, nurse, chemical dependency counselor, social worker, member of the clergy, marriage and family therapist, mental health service provider, licensed professional counselor, or other person, whether or not licensed by the state, who performs or purports to perform psychotherapy.” Psychotherapy is defined as “the professional treatment, assessment, or counseling of a mental or emotional illness, symptom, or condition.” A patient is defined as “a person who seeks or obtains psychotherapy” and a former patient is defined as “a person who was given psychotherapy within two years prior to sexual contact with the psychotherapist.”
The Statute requires employers to contact current or former employers of who employed the above named individual as a psychotherapist within the last five years. Employers or former employers may be liable under the statute if they fail or refuse to take any action required by the statute. No cause of action arises against employers or former employers who act in good faith making these inquiries and/or responding to such inquiries.
People Incorporated formally requests any and all information concerning requests for and occurrences of sexual contact between the above named individual and patients or former patients during the time the individual was employed by you as a psychotherapist as defined in Minnesota Statute 604.20. Please complete the form provided.
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MS604.20—Sexual Exploitation Background Check
Employee Completes
I authorize People Incorporated to contact my current or former employers for the purpose of complying with Minnesota Statute 604.20 relating to the sexual exploitation of patients by psychotherapists. I further authorize any and all of my current or former employers to provide whatever information is necessary to assist People Incorporated in complying with this statute. I hereby release any former employer, schools, or persons from all liability in responding to this inquiry.
Employee Name (Print): Maiden (Print):______
______
Employee Signature SSN (Optional)Date
Current/Former Employer Information
Name of Business
Contact Name/Supervisor Name
Street Address
_____
City State Zip Code
Phone Number
Current/Former Employer Completes
We have no record or knowledge of the above named individual having sexual contact with patients or former patients, as defined in Minnesota Statute 604.20.
We do have record or knowledge of the above named individual having sexual contact with patients or former patients, as defined in Minnesota Statute 604.20.
Name of Person Completing Form: ______Title:______
If you are aware of such contact, please provide details of information.
______
Phone Number where we may contact you for further information:______
Signature:______