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#19-001565-0002
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 possess a Master's or Doctoral degree in a health or human services counseling field from an accredited college or university by the Board of Professional Counselors and Therapists or completion of a program of studies judged by the Board to be substantially equivalent in subject matter and training?

If "yes", please indicate the name of the school where degree was earned, degree type (Master's, Doctoral, etc.), field of study, and the date the degree was earned in the space below.


 
If you answered "yes" to the previous question, please submit a copy of your transcripts (transcripts may be unofficial) documenting the completed degree and related coursework with your application.


 

TRANSCRIPTS ARE NEEDED TO DETERMINE IF APPROPRIATE COURSEWORK HAS BEEN COMPLETED TO QUALIFY FOR THIS POSITION.  FAILURE TO PROVIDE TRANSCRIPTS AT TIME OF APPLICATION WILL RESULT IN DISQUALIFICATION.


2

Describe your experience working with clients in a behavioral health program.

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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