Department of Budget and Management

**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.**

Are you licensed as a Psychologist from the Maryland Board of Examiners of Psychologists?  (If you respond Yes, please upload a copy with your application)

If you answered Yes to the above question, please provide your license number and expiration date in the space below.  If you do not possess a certificate of eligibility, please indicate N/A in the text box below.

When did you receive your license as a Psychologist?  Include month and year in the space below (i.e., May 2010).

Describe your experience rendering psychological services or engaged in psychological research after receipt of your license as a psychologist.  Do not include experience prior to receiving your license. With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must also be reflected in the "Work Experience" section of your application.  If you do not have this experience, put N/A in the box below.

Describe your experience working with adults with intellectual disabilities, ID forensic populations, and/or co-occurring diagnoses, such as Autism.

This experience must be included in your application. Please provide the employer's name, your job title, dates of employment, and hours worked per week. If you do not have experience in this area, please enter "N/A" in the text box below.

Describe your supervisory experience and oversight for development of Behavioral Support plans.

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.

Describe your experience and/or skills in assessment, CBT, BSCA certification.

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.