**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.
Do you possess a Bachelor's degree in Nursing, Social Work, Psychology, Education, Counseling or a related field?
Yes
No
2.
Do you possess a Master's degree in health or human services?
Yes
No
3.
Describe your professional work experience in health services. 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.
4.
Do you possess a LCPAT (Licensed Clinical Professional Art Therapist) license from the Maryland Board of Professional Counselors and Therapists?
Yes
No
5.
Do you currently possess a license as a Licensed Clinical Professional Counselor (LCPC) from the Maryland Board of Professional Counselors and Therapists?
Yes
No
6.
Are you approved, or eligible to be an approved clinical supervisor by the Maryland Board of Professional Counselors and Therapists? If yes, please attach documentation to application. If no, please indicate N/A in the text box.
Yes
No
7.
Describe your knowledge of and/or experience with group therapy and working with at risk youth.
This experience must be included on your application.
8.
Do you have supervisory experience? If yes, please describe in detail and include name of employer(s) where you gained this experience, dates of employment, and relevant job duties. If no, please enter N/A.
Department of Budget and Management