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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.**



Do you possess a current certification as a Peer Recovery Specialist from the Maryland Addictions Professionals Certification Board (MAPCB)?  If so please attach a copy with your application.

Yes No

Are you able to document that you have been in a state of recovery from a substance use, mental health or co-occuring disorder for at least 2 years?

Yes No

Describe your experience providing peer recovery support services.

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, put N/A in the box below.

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