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#20-000314-0001
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

This position is limited to current employees of the Charles County Health Department's Behavioral Health Unit only.

Are you are current current employee of the Charles County Health Department's Behavioral Health Unit?

Yes No
2

Do you currently possess a license as a Licensed Clinical Professional Counselor (LCPC) from the Maryland Board of Professional Counselors and Therapists?

Yes No
3

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.

4

Describe your experience providing professional counseling to clients with mental health disorders by using assessment, evaluation, intervention, rehabilitation and treatment regimens.

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.


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