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#21-001562-0005
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

Do you possess a Bachelor's degree in a health or human services counseling field from an accredited educational institution approved by the Board of Professional Counselors and Therapists OR completion of a program of studies judged by the Board to be substantially equivalent in subject matter and training?

If "yes", please indicate the name of the school where degree was earned, degree type (Master's, Doctoral, etc.), field of study, and the date the degree was earned in the space below. If no, please indicate N/A in the text box.

2

In accordance with Health Occupations Title 17 and Code of Maryland Regulations 10.58.07, candidates must apply for and receive a letter of authorization to practice as a trainee from the Board of Professional Counselors and Therapists within 90 days of their date of hire.  Do you possess a letter of authorization to practice as a trainee from the Board? If yes, please upload copy of letter with application.

Yes No

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