**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 current license as a Graduate Professional Counselor from the Maryland Board of Professional Counselors and Therapists?
Yes
No
2
If you answered Yes to the above question, please provide your license number and expiration date in the space below. If you do not possess a certificate of eligibility, please indicate N/A in the text box below.
3
Describe your experience working with the Mental Health population.
Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application. If you do not possess experience in this area, put N/A in the box below
4
Describe your experience providing individual and family therapy services.
This experience must be identified in the Work Experience section of the application, including dates and hours worked and a description of the job duties performed. If you do not possess this type of experience, please indicate N/A in the text box.
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