Official SealSan Joaquin County Human Resources Division


#0125-RS2013-AC
Supplemental Questionnaire

Last Name
First Name
 

You are applying for a position with potential placement or referral to Correctional Health Services, which provides health care to adult inmates at the San Joaquin County jail facility.

A candidate must successfully pass the security clearance, initiated through a background investigation conducted by the Sheriff’s Office. The background investigation requires the completion of an extensive questionnaire called “Personal History Questionnaire” and is used by the Sheriff’s Office to conduct the background investigation. 

The security clearance is a mandatory condition of employment, and the loss of the security clearance will result in termination from County employment in accordance with the rules and regulations governing County employment.

 

By answering YES below you are acknowledging the following:

I understand that if I successfully pass the background investigation and obtain the security clearance, I will be expected to maintain my security clearance as a condition of my employment and failure to do so will result in the termination of my employment with the County in accordance with County rules and regulations

Yes No
1

Have you graduated from an accredited university with a master's or doctorate degree in social work, counseling, psychology or other course of study acceptable to the State of California Board of Behavioral Sciences towards licensure as a Licensed Clinical Social Worker (LCSW), Marriage and Family Therapist (MFT), Licensed Professional Clinical Counselor (LPCC), or Psychologist?

Yes No
1a

If you answered yes, please provide the following information: Degree type, discipline/emphasis, and university attended.

2

Describe at least three years of full-time paid progressively responsible counseling or therapy in clinical or treatment casework experience.

Include the following:

  • Employer
  • Dates of Employment
  • Specific work performed
2a

Describe at least 6 months of full-time paid progressively responsible licensed casework experience as a LCSW, MFT, LPCC, or Psychologist which included counseling or therapy in a clinical or treatment setting.

Include the following:

  • Employer
  • Dates of employment
  • Specific work performed
3

In order to qualify, applicants must possess and maintain a valid California license of one of the following:

Marriage and Family Therapist (MFT) issued by the California Board of Behavioral Sciences (BBS)
Licensed Professional Clinical Counselor (LPCC) issued by the California Board of Behavioral Sciences (BBS)
Licensed Clinical Social Worker (LCSW) by the California Board of Behavioral Sciences
Licensed Psychologist issued by the California Board of Psychology
none of the above
4

Employment history is considered in the background investigation process. Have you ever been terminated from a job or resigned from a job to avoid termination (not including involuntary layoff)?

Yes No
4a

If you answered yes, provide the name of employer and date of separation: