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#18-002344-0004
Supplemental Questionnaire

Last Name
First Name

 

**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 Bachelor's degree in Nursing, Social Work, Psychology, Education, Counseling or a related field?

Yes No
2.

Do you possess a Master's degree in health or human services?

Yes No
3.

Describe your professional work experience in health services. 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 professional experience related to the treatment and services for mentally ill patients. 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.

5.

Describe your experience working with transition age youth and young adults.  This experience should also be included in your application.  If you do not possess this type of experience, indicate N/A in the text box below.

6.

Describe your knowledge of Maryland's public behavioral health systems of care to children and adolescents including inpatient psychiatric services and Medicaid.

7.

Describe your experience in writing grants and monitoring contracts.

With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.   If you do not have this experience, put N/A in the box below.


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