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#24-002004-0002
Supplemental Questionnaire

Last Name
First Name
1.

Are you currently licensed as an LMSW or LCSW-C?

Yes No
2.

Please describe your experience working in a forensic social work setting.  Include employer, duties and dates of employment.  If no experience, indicate N/A.

3.

Describe your experience writing biopsychosocial evaluations.  Include employer, duties, and dates of employment and number of hours worked per week.  If no experience, indicate N/A.

4.

Describe your experience which required you to utilize excellent writing skills.  Include employer, duties and dates of employment.  If no experience, indicate N/A.

5.

Do you have experience testifying in court?  If yes, please describe your experience.  Indclude employer, duties and dates of employment.  If no, please indicate NA


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