**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 have 60 credit hours from an accredited college or university with a minimum of 12 credit hours in mental health, health, human services, education, or related behavioral sciences including six (6) credit hours in psychology, counseling, addictions or mental health? Please upload transcripts to application. Unofficial transcripts are acceptable.
Yes
No
2
Do you possess a Bachelor's degree from an accredited college or university with 30 credit hours in mental health, health, human services, education, or related behavioral sciences including 6 credit hours in psychology, counseling, addictions or mental health?
Yes
No
3
If yes, please list the required coursework (thirty credits in mental health, health, human services, education, or related behavioral sciences including six credit hours in psychology, counseling, addictions or mental health) in the space below using the following format. You must also attach a copy of your official or unofficial transcripts to your application:
Example: Course Number Title Credits Earned
PSY 101 Introduction to Psychology 3.0
*This information will be verified upon employment.
4
Describe your experience providing counseling or other therapeutic mental health services to seriously mentally ill children or adolescents. 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, please indicate N/A in the box below.
5
Describe your experience working with adolescents with emotional disabilities and court-involved youth.
This experience must be identified in the Work Experience section of the application, including dates and hours worked and a description of the job duties performed. If you do not possess this type of experience, please indicate N/A in the text box.
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