Official SealHuman Resource Services Department

Supplemental Questionnaire

Last Name
First Name

Applicants for this position are required to submit responses to the following supplemental questions.  Your completed responses to the supplemental questionnaire will be evaluated to determine your qualifications and must be completed properly in order to be given full consideration for the next phase in the selection process. Additionally, your responses will also be evaluated and used in the selection process in order to identify the best qualified applicants. 

Responses should be thorough and specific.  A lack of detail and explanation in the supplemental questions and in your application may result in failure or disqualification for this position.  Clarity of expression, content, experience, grammar, spelling and the ability to follow instructions will be considered in the evaluation process.  A resume will not be accepted as a substitute for properly completed responses.

Information provided in your responses to the supplemental questionnaire regarding your employment experiences must also be detailed in the Work Experience section of the application for this recruitment.  Please be sure to list all employers and required information, on your application, especially if you are referencing those employers in your responses to the supplemental questions.

The supplemental questions were designed to elicit your experience as it relates to the current recruitment in order to identify the best qualified candidates for this position.  Only the best and most suitably qualified candidates will be invited to participate in the oral interviews. 

By selecting yes below, you certify your understanding that all applicants who meet minimum qualifications are not guaranteed to move forward in the process.  Do you understand the above statement?

Yes No

Please list below the state license(s) you possess which qualify you for this position.  Be sure to include all of the following:

  • License Title (i.e.: LCSW; MFT; Clinical Psychologist)
  • License issuing authority/board
  • License number
  • Date license initially issued
  • Expiration date of license

Describe your experience providing paid post-license clinical services in direct behavioral health care that includes treatment and disposition planning and/or the clinical review of direct mental health care services.   In your response, be sure to include the name of your employer, the duration of your employment, your title, role, and level of responsibility.


Please describe your experience as a licensed behavioral health clinician working specifically within each of the settings below. In your response, be sure to include the name of your employer, the duration of your employment working in each unit, your title, role, and level of responsibility.

  • A High Volume Call Center Unit
  • A Utilization Management Program or Authorization Services Unit
  • A Quality Assurance Unit

Please describe your experience providing initial telephone information; performing screening, assessment, and referral services to behavioral health care consumers including telephone crisis intervention services.


Please describe your experience providing daily case consultation and review to determine medically necessary treatment and appropriate utilization of system resources for both inpatient and outpatient behavioral health services.


Please describe your experience assessing quality of care and documentation required to support continued treatment, conducting audits, investigating complaints, and monitoring compliance with regulations.


This position requires applicants possess a valid California Motor Vehicle Operator's license. Can you meet this requirement prior to appointment into this position?

Yes No

In compliance with the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), employees in this classification are required to possess a National Provider Identifier (NPI) number prior to their first day on the job. Can you meet this criteria?

Yes No