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#19-000214-0009
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 current certification as a Peer Recovery Specialist from the Maryland Addictions Professionals Certification Board (MAPCB)?  If so please attach a copy with your application.
Yes No
2.

Do you self-identify as someone who is in recovery from alcohol or other drug abuse?
Yes No
3.

Are you able to document 2 years in recovery?
Yes No

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