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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.***


Are you currently licensed as an LCSW-C or LMSW in Maryland? If not, please list when you anticipate being eligible for licensure and what requirements are still outstanding.


Describe your experience providing forensic social work services.  This experience must also be included in your application.  If you do not possess this type of experience, please indicate N/A in the text box.


Describe your experience conducting screening interviews and assessments and developing treatment plans including employer name, dates of employment, and job duties.  If you do not have this experience please enter N/A. 


List which grant population(s)/issue(s) you are particularly interested in working with: substance abuse, mental health, reentry of long sentence servers, parents in abuse/neglect proceedings, youth charged as adults, other (please specify); and describe any prior experience working with that population(s).

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