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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.***


Do you possess a bachelor’s degree from an accredited college or university in nursing, social work, psychology, education or counseling?

Yes No

What field of study is your degree in?


Describe your experience with professional work in health or medical services in areas, other than Mental Health, Developmental Disabilities or Addictions. 

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.

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