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#20-002008-0001
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess a current license as a Certified Social Worker, Clinical (LCSW-C) from the Maryland Board of Social Work Examiners?  If yes, please attach your license.

Yes No
2.

Please describe your experience providing clinical and therapeutic social work services to clients requiring rehabilitative counseling or forensic social work services, including your experience completing assessments, formulating diagnostic impressions, treating mental disorders and other conditions or providing psychotherapy as a Certified Social Worker, Clinical (LCSW-C).  Include the name of the employer and dates of employment and hours per week worked. If you do not have this experience, please enter N/A.

3.

Please describe your experience supervising lower level social workers and/or coordinating or leading an adolescent/youth focused behavioral health team within the criminal justice system.  Please provide the name of the employer and dates of employment and hours per week worked. If you do not have this experience, please enter N/A.

4.

Do you have one year of experience providing Mental Health treatment to youth?

If yes, please describe your experience providing mental health treatment to youth. Include the name of the employer and dates of employment and hours per week worked.  If you do not have this experience, please enter N/A.

5.

Please describe your experience providing behavioral health services to troubled adolescents and their families along with your experience coordinating or leading an adolescent/youth focused behavioral health team within the criminal justice field.  Include  the name of the employer and dates of employment and hours per week worked. If you do not have this experience, please enter N/A.


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