**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.
Explain your professional work experience related to treatment and services to persons with alcohol or other substance abuse addiction. 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.
2.
Describe your knowledge of treatment resources.
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.
3.
Describe your knowledge of and/or experience working with the American Society of Addicted Medicine (ASAM) criteria.
4.
Do you possess a current certification/license issued by the Maryland Board of Professional Counselors as an Alcohol/Drug Counselor (any level)?
Yes
No
5.
What type of certification/license do you possess? If none, enter N/A.
6.
Do you possess a Bachelor's degree in Nursing, Social Work, Psychology, Education, Counseling or a related field?
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