**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 have at least four years of experience rendering clinical social work services in a health care or treatment setting subsequent to the receipt of an approved Master's degree in Social Work?
Yes
No
2.
Describe your professional work experience rendering clinical social work services in a health care or treatment setting subsequent to the receipt of an approved Master's degree in Social Work from an accredited college or university.
Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application. If you do not possess experience in this area, put N/A in the box below.
3.
Do you possess two years experience directing a clinical services program or unit or supervising Social Workers with Master's degrees?
Yes
No
4.
If you responded YES to the above question, please describe your experience directing a clinical services program or unit or supervising Social Workers with Master's degrees.
This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.
5.
Describe your experience with the provision of clinical supervision in the areas of the provision of Dialectical Behavior Therapy, Cognitive Behavioral Therapy and the use of person-centered treatment modalities.
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.
6.
Describe your experience with the provision of therapy for the seriously mentally ill and forensic population.
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.
7.
Describe your experience administering therapy programming for hospital systems and/or outpatient clinics.
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.
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