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#18-000313-0003
Supplemental Questionnaire

Last Name
First Name
1

Do you have a license from the Maryland State Board of Professional Counselors and Therapists as Licensed Clinical Professional Counselor?  If you do possess the appropriate license, then please submit a copy of your license with your application.

Yes No
2

Please describe your experience working with an adolescent population with mental health and or substance abuse issues. Please include the setting and type of interventions or treatments you applied. Provide the name of the employer(s) and dates you performed this responsibility and hours per week. If no experience, indicate N/A.

3

Please describe your experience assessing and treating a population of youth in the juvenile justice system with substance abuse disorders.  Provide the name of the employer(s) and dates you performed this responsibility and hour per week.  If no experience, indicate N/A.    


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