**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 current license as a Certified Social Worker, Clinical (LCSW-C) from the Maryland Board of Social Work Examiners? If yes, please attach your license.
Yes
No
2.
If you answered Yes to question 1, please provide your license number and expiration date in the box below. If No, please enter N/A in the box below.
3.
Please indicate the date that you earned your Master's degree in Social Work in the space below (i.e., May 2010). If you do not have a Master's degree in Social Work, put N/A in the space below.
4.
Describe your professional work experience rendering clinical social work services in a health care or treatment setting subsequent to the receipt of an approved Master's degree in Social Work from an accredited college or university.
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.
5.
Describe your social work experience in an area of clinical speciality.
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.
6.
Are you eligible for or possess approval from the Maryland Board of Professional Counselors and Therapists to supervise alcohol and drug counselors?
Department of Budget and Management