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#24-004667-0002
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

Do you possess a Bachelor's degree from an accredited college or university with 30 credit hours in mental health, health, human services, education, or related behavioral sciences including 6 credit hours in psychology, counseling, addictions or mental health?

Yes No

 

If you responded YES to the above question, please upload a copy of your transcript(s) to the application. Unofficial version(s) of the transcript(s) are accepted.


2

Describe your experience coordinating and providing distinct interventions unique to the individual physical, mental, learning and social development and therapeutic treatment needs of seriously mentally ill children and adolescents in a therapeutic mental health setting.

With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must be reflected in your application.  If you do not have this experience, put N/A in the box below.

3

Describe your experience working with adolescents with emotional disabilities and court-involved youth.

This experience must be identified in the Work Experience section of the application, including dates and hours worked and a description of the job duties performed. If you do not possess this type of experience, please indicate N/A in the text box.


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