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#23-004176-0001
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

Are you currently licensed by the Maryland State Board of Professional Counselors and Therapists as a Clinical Professional Art Therapist (LCPAT)?  If yes, please attach a copy of your license.

Yes No
 

If you answered Yes to the previous question, please provide the license number and expiration date in the box below.  A copy of your current license or license verification should also accompany your application.


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