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#21-000311-0011
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 Mental Health License (i.e., Counseling, Psychology, or Social Work)?  If yes, please specify type of license and license number.  If no, indicate N/A.

2.

Do you possess at least two years of experience assessing and/or providing therapy to population of adolescents with mental health and/or substance abuse disorders in the Juvenile Justice system? If yes, please describe your experience.  Include the employer name, dates of employment, job duties and hours worked per week. If you do not have this experience, indicate N/A.

 

3.

Describe your experience working with an adolescent population with mental health and/or substance abuse issues. Please include the name of your employer, the dates of employment, job duties and the number of hours worked per week. If you do not have this experience, type N/A.

4.

Do you possess at least two years of experience supervising Behavioral/Mental Health Professionals? If so, please describe your experience.  Include the employer name, dates of employment, job duties and hours worked per week. If you do not have this experience, indicate N/A.


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