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#19-002243-0002
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 60 credit hours at an accredited college or university including 15 credit hours in a human service program?  A copy of your transcript must be attached to your application.

Yes No
2

Do you possess either a supervised practicum in providing counseling or other therapeutic services to the mentally ill or at least nine credit hours in psychology, including abnormal psychology? A copy of your transcript must be attached to your application.

Yes No

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