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#24-000312-0002
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 currently possess a license as a Licensed Clinical Professional Counselor (LCPC) from the Maryland Board of Professional Counselors and Therapists?

Yes No
2.

If you answered "yes", please provide your license number and expiration date below.  You may also submit a copy of your license or license verification with your application.


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