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#21-002589-0054
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess a Mental Health License (i.e., Counseling, Psychology, or Social Work)?  If yes, please specify type of license and license number.  If no, indicate N/A.

2.

Describe your experience assessing and providing therapy to population of adolescents with mental health or substance abuse disorders in the Juvenile Justice system. Please include employers name, dates of employment, job duties and hours worked per week. If you do not have this experience, type N/A.

3.

Describe your experience working with an adolescent population with mental health and/or substance abuse issues. Please include the name of your employer, the dates of employment, job duties and the number of hours worked per week. If you do not have this experience, type N/A.

4.

Do you possess at least two years of experience supervising Behavioral/Mental Health Professionals? If so, please describe your experience.  Include the employer name, dates of employment, job duties and hours worked per week. If you do not have this experience, indicate N/A.


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