Licensee Psychological and Emotional Health Declaration 8.21.2014 Page 1 of 1
TEXAS COMMISSION ON LAW ENFORCEMENT
6330 E. Highway 290, STE 200, Austin, Texas 78723-1035
Phone: (512) 936-7700
http://www.tcole.texas.gov
LICENSEE PSYCHOLOGICAL AND EMOTIONAL HEALTH DECLARATION (L-3)
Commission Rule 217.01, 217.1, 217.7, 221.35
INDIVIDUAL INFORMATION
1. TCOLE PID
2. Last Name 3. First Name 4. M.I. 5. Suffix (Jr., etc.)
6. Home Mailing Address
7. City
8. State
9. Zip Code
Is this exam for a student enrolling in an academy? Yes No.
If yes, check one Peace Officer County Corrections Telecommunicators School Marshal
Attention Requesting Agency: State Law and Commission Rule require that this psychological examination be
performed by a licensed psychologist or a psychiatrist except in an exceptional circumstance when, upon prior
approval by the Commission, it may be performed by a qualified licensed physician. The Chief Administrator of the
requesting agency must request prior approval in writing and must receive specific written approval before an examination
under exceptional circumstances is acceptable.
APPOINTMENT (Do not check if student)
10
. Peace Officer Reserve Officer County Jailer Telecommunicator School Marshal
Juvenile Probation Officer Public Security Off.
ACADEMY / DEPARTMENT INFORMATION
11. TCOLE Number 12. Agency/Academy Name
13. Mailing Address
14. Ci ty
15. County
16. Zip Code
17. Phone Number
Attention Examining Professional: State Law and Commission Rule require that this psychological examination be
performed by a licensed psychologist or a psychiatrist except in an exceptional circumstance when, upon prior
approval by the Commission, it may be performed by a qualified licensed physician. The agency must request prior
approval in writing and must receive specific written approval before an examination under exceptional circumstances is
acceptable.
STATEMENT OF EXAMINER: (Please check the appropriate box and provide the requested information)
I am a [ ] Licensed Psychologist, [ ] Psychiatrist, and I certify that I have completed a psychological
examination of the above named individual pursuant to professionally recognized standards and methods. I have
concluded that, on this date, the individual IS in satisfactory psychological and emotional health to perform the duties,
accept the responsibilities and meet the qualifications established by the appointing agency.
Examiner:_____________________________________________________________________________________________
Name (type or print) State License Number
Mailing Address:________________________________________________________________________________________
Street City State Zip
Phone Number:_______________________________ Date of Examination(s) ______________________________________
_____________________________________________________________________________________________________
Signature Date
THIS DECLARATION IS NOT PUBLIC INFORMATION AND IS VALID UNLESS WITHDRAWN OR INVALIDATED, AND
IS VALID ONLY IF SIGNED BY A LICENSED PSYCHOLOGIST OR PHYSICIAN.
