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#19-001568-0004
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.***


1.

Are you a Certified Professional Alcohol and Drug Counselor or a Licensed Clinical Alcohol and Drug Counselor with the Maryland Board of Professional Counselors and Therapists? If you responded yes, please provide your license number and full expiration date in the box below. If you do not have this experience, enter N/A

2.

Do you have experience providing substance abuse/behavioral/mental health treatment to adolescents/at-risk juveniles in a secure juvenile setting or facility? If you have this experience provide the name of the employer and the dates of employment when you performed this work and the hours per week you performed this work. If you do not have this experience, enter N/A

3.

Do you have experience supervising substance abuse/behavioral/mental health professionals? If you checked Yes, please be specific in fully describing this experience in the box below. Include employer(s) and date(s) of employment. This information must also be included in your application in order to receive credit. If you do not have this experience, enter N/A


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