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#19-001565-0004
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 providing substance abuse counseling to youth. Include place of employment, dates and job duties. If no experience, indicate N/A.

2.

Describe your experience creating treatment plans. Include place of employment, dates and job duties. If no experience, indicate N/A.

3.

Describe your experience performing intakes and assessments for admission to alcohol and drug treatment programs. Include place of employment, dates and job duties. If no experience, indicate N/A.

4.

Describe your case management experience. Include place of employment, dates and job duties. If no experience, indicate N/A.

5.

Describe your experience in crisis intervention. Include place of employment, dates and job duties. If no experience, indicate N/A.

6.

Do you have a Letter of Authorization issued by the Maryland Board of Professional Counselors and Therapists? (If Yes, please upload a copy with your application).

Yes No
7.

Do you have a CSC or CAC issued by the Maryland Board of Professional Counselors and Therapists? (If Yes, please upload a copy with your application).

Yes No

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