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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 currently possess a license as a Certified Professional Counselor-Alcohol and Drug OR Licensed Clinical Alcohol and Drug Counselor from the Maryland Board of Professional Counselors and Therapists?

Yes No

If you answered yes, please attach a copy of your license to your application.  Also, provide the license number and expiration date below.

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