**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
Describe your experience conducting group therapy with an adult population, especially adults with a mental illness.
This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.
2
Describe your experience in the practice of inpatient psychiatric care and administration. Information must also be reflected on your resume.
3
Do you have experience providing clinical social work services in an area of clinical specialty?
Yes
No
4
If you responded YES to the above question, please indicate your area of clinical specialty.
5
Do you possess a current license as a Certified Social Worker, Clinical (LCSW-C) from the Maryland Board of Social Work Examiners?
Yes
No
6
If you answered Yes to the above question, please provide your license number and expiration date in the space below. If you do not possess a certificate of eligibility, please indicate N/A in the text box below.
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