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#19-004452-0007
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 have 60 credit hours from an accredited college or university with a minimum of 12 credit hours in mental health, health, human services, education, or related behavioral sciences including six (6) credit hours in psychology, counseling, addictions or mental health?  Please attach transcript to application.  Unofficial transcripts acceptable.

Yes No

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