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#20-001568-0002
Supplemental Questionnaire

Last Name
First Name

 

PLEASE ANSWER ALL SUPPLEMENTAL QUESTIONS COMPLETELY.  PLEASE INCLUDE NAME(S) OF EMPLOYER(S) JOB TITLE(S) DATES OF EMPLOYMENT AND HOURS WORKED PER WEEK.  ALL SUPPLEMENTAL INFORMATION MUST ALSO BE REFLECTED IN YOUR APPLICATION.  DO NOT COPY AND PASTE FROM YOUR RESUME.


1

In accordance with Health Occupations Title 17 and Code of Maryland Regulations 10.58.07, candidates placed in this classification must be licensed by the Board of Professional Counselors and Therapists as a Licensed Clinical Alcohol and Drug Counselor or as a Certified Professional Counselor-Alcohol and Drug on or before September 30, 2008.

Do you possess a Licensed Clinical Alcohol and Drug Counselor (LCADC) or Certified Professional Counselor-Alcohol and Drug (CPC-AD) license from the MD Board of Professional Counselors and Therapists?  If yes, please indicate the license you possess and include your license number and expiration date in the text box.

2

Explain your experience with the drug/alcohol population?

3

Describe your experience working with patients with serious mental illness.

4

Describe your experience supervising lower-level alcohol and drug counselors.


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