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#23-000312-0017
Supplemental Questionnaire

Last Name
First Name

 

***Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.***


1.

Do you possess a Licensed Clinical Professional Counselor (LCPC) license from the Maryland Board of Professional Counselors and Therapists? If yes, please provide the license number and expiration date in the box below. A copy of your current license or license verification should also accompany your application.


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