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#24-001561-0002
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 current license as a Certified Supervised Counselor- Alcohol and Drug (CSC-AD) from the Maryland Board of Professional Counselors and Therapists? 

Yes No
2.

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.

3.

Describe your experience working with the criminal justice system.

This experience should be included on your application, including hours and dates worked. If you do not possess this type of experience, please put N/A in the text box.

4.

Describe your experience running group sessions.

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.


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