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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 Master's or Doctoral degree in a health or human services counseling field?

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.


Do you possess a current license as a Licensed Graduate Alcohol and Drug Counselor (LGADC) from the Maryland Board of Professional Counselors and Therapists?

Yes No

If you answered Yes to the previous question, please provide the license number and expiration date in the box below.  A copy of your current license or license verification should also accompany your application.

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