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#18-004509-0001
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.***


1.

Do you possess a bachelor's degree from an accredited college or university in any of the following specific majors?

Applied Psychology, Behavioral Science, Child Development, Clinical Psychology, Counseling, Counseling Psychology, Counseling Services, Criminology, Forensic Psychology, Family Science, Family Studies, Family and Human Services, Human Development, Human Growth and Development, Human Services, Industrial and Organizational Psychology, Juvenile Justice , Mental Health, Nursing, Pedology, Psychology, Rehabilitation Counseling, Sociology, or Social Work.

Yes No
 

If ''Yes,'' please indicate the specific title of your Bachelor''s degree major, the date you received your Bachelor''s degree and your College''s name and location.

2.

If you answered 'No' to Question 1, do you possess a Bachelor's degree from an accredited college or university in Human Resources Management or a different behavioral science major other than those listed in Question 1 that includes at least 30 credit hours in Human Services or Human Development? (If you answered 'Yes' to the first question, put 'N/A' in the box below.)

 

If 'Yes,' please indicate your bachelor's degree major, the date you received your Bachelor's degree and your College's name. You must also list your human service or human development-related coursework below (include the title of the class, the course number and the number of credits you earned for passing the course) or, alternatively, attach a legible copy of your college transcript.

Course Title, Course Number and Number of credits earned:

3.

Do you possess a Social Work Associate license from the Maryland State Board of Social Work Examiners?

Yes No

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