Department of Budget and Management

#13-002005-001
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 full credit. Applications that do not include a supplemental questionnaire will be considered incomplete and may be subject to disapproval.***

Please check the appropriate box that applies to your Social Worker License status.

I am currently licensed as a certified Social Worker-Clinical by the MD State Board of Social Worker Examiners. If so, please submit a copy of your certification.

I am not currently licensed as a certified Social Worker-Clinical by the MD State Board of Social Worker Examiners; but I have applied to obtain the license and am pending receipt of the license.

I am not licensed as a certified Social Worker-Clinical by the MD State Board of Social Worker Examiners and have not applied for a license.

Please describe your experience working with an adolescent population with mental health and or substance abuse issues. Please include the setting and type of interventions or treatments you applied. Provide the name of the employer(s) and dates you performed this responsibility. If no experence, indicate N/A.

Department of Budget and Management

#13-002005-001 Supplemental Questionnaire

#13-002005-001
Supplemental Questionnaire