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#19-002587-0053
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

Describe your experience supervising, managing, and evaluating the work of subordinates.  Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your resume.  If you do not possess experience in this area, put N/A in the box below. 

2

Describe your experience monitoring and managing budgets.

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.

3

Describe your experience with community resources.  Include name of employer, job title, dates employed, and hours worked per week for each relevant position.  If you do not have this experience, put N/A in the box below.

4

Describe your experience providing licensed professional counseling and therapy.

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.

5

Do you possess a current Maryland license as a Certified Social Worker-Clinical (LCSW-C) or current license as a Maryland Clinical Professional Counselor (LCPC)?  Please attach a copy of your license with your application.

Yes No
6

If you responded YES to the above question, please provide your license number and expiration date in the text box below.


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