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#19-004515-0002
Supplemental Questionnaire

Last Name
First Name
1.

Describe your experience in child welfare services (public or private agency).   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, indicate N/A.

2.

Describe your experience providing clinical services to children and families.  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, indicate N/A.

3.

Describe your experience preparing treatment plans/strategies.  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, indicate N/A.

4.

Do you possess a current license as a Certified Social Worker, Clinical (LCSW-C) from the Maryland Board of Social Work Examiners? 

Yes No

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