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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.**



Do you possess a current certification as a Peer Recovery Specialist from the Maryland Addictions Professionals Certification Board (MAPCB)?  If so please attach a copy with your application.

Yes No

Are you able to document that you have been in a state of recovery from a substance use, mental health or co-occuring disorder for at least 2 years?

Yes No

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