Official SealHuman Resource Services Department

Supplemental Questionnaire

Last Name
First Name

IMPORTANT:  Applicants for this position are required to submit responses to the following supplemental questions. 

By selecting yes below, you certify your understanding that all applicants must meet minimum qualifications in order to move forward in the process.  Do you understand the above statement?

Yes No

This position requires possession of a valid clinical license in good standing from the one of the applicable licensing authority: California Board of Behavioral Sciences, California Board of Psychology, or California Board of Nursing. Valid licenses include the following:

  • Licensed Clinical Social Worker
  • Licensed Marriage & Family Therapist
  • Licensed Professional Clinical Counselor
  • Licensed Psychologist
  • Licensed Nurse Practitioner
  • Licensed Clinical Nurse Specialist

In the space below, please provide the following information related to each of the qualifying clinical licenses listed above that you possess which best qualifies you for this position:

•License Title

•License Effective Date

•License Expiration Date


Please indicate your additional job-related training and/or education beyond that required by the minimum qualifications.


Please describe in detail your post license experience as a behavioral health/mental health clinician providing clinical and/or case management services specifically in a behavioral health managed care or related setting.  In your response, please include the following: 

  • Employer name
  • Job Title
  • Start date & end date of employment
  • Hours worked per week
  • Your specific role/responsibility

To claim veterans’ preference points, you must upload a copy of your honorable discharge (DD-214) form to this application under the resume tab. Do you claim veterans’ preference points?

Yes No

To claim veterans' preference points related to a service-connected disability attach proof from the Veteran's Administration of your current disability of 10% or more by uploading it to your application under the resume tab. Do you claim veterans' preference points related to a service-connected disability?

Yes No

I understand in compliance with the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as a condition of employment that employees in this classification are required to possess a National Provider Identifier (NPI) number prior to their first day on the job and I can meet this requirement. 

Yes No

In compliance with Medicare regulations, eligible licensed clinicians in this classification are required to complete the "Medicare Enrollment Process for Physicians and Non-Physician Practitioners" through the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services, prior to their first day on the job. Active enrollment in Medicare is a condition of employment. Failure to attain or maintain active enrollment will result in termination. Do you understand that if you are identified as an eligible licensed clinician you will be required to meet this standard?

Yes No