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#21-001562-0006
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 have a minimum of a Bachelor's degree in a Health or Human Services counseling field OR a Bachelor's degree in a program of study with a counseling emphasis AND 1 credit in Alcohol and Drug Ethics?  If yes, you must submit a copy of your transcripts documenting the completed coursework with your application.

Yes No
2.
If you answered no to question #1, do you have a Bachelor's degree in another field plus 15 credits in the following:
 
- Pharmacology of Psychoactive Drugs
- Individual Counseling
- Group Counseling
- Abnormal Psychology
- Addictions treatment delivery
- Human Grown and Development
- Topics in Alcohol and Drug dependency
- Family Counseling
- Theories of Counseling
 
AND 1 credit or 15 CEU's in Ethics with a focus on alcohol and drug counseling?
 
If you answered yes to the previous question, please submit a copy of your transcripts (transcripts may be unofficial) documenting the completed coursework with your application.
Yes No

 

If you do not submit a transcript with your application, you must list the required coursework on your application. You will be required to submit a transcript at the time of interview.



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