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Santa Cruz County Personnel Department
#24-SK5-AA


Supplemental Questionnaire

Last Name First Name
 
 

Do you possess a master's degree or PhD with a major in social work, psychology, clinical counseling, psychiatric nursing or a closely related behavioral science field which has included completion of a university approved internship, preferably a clinical internship, in a mental health agency AND Two years of experience providing treatment, counseling, or case management services to clients in a mental health setting?

Yes
No
 

Do you possess any of the following licenses: 

Clinical Social Worker
Marriage and Family Therapist
Licensed Professional Clinical Counselor
Clinical Psychologist
I do not possess any of these licenses
 

Are you a certified Alcohol and Drug certified counselor? 

Yes
No
 

Do you have experience providing mental health services for children or youth clients? 

6-12 months experience
13-24 months experience
25-36 months experience
I do not have this type of experience
 

Do you have experience providing mental health services for adult clients? 

6-12 months experience
13-24 months experience
25-36 months experience
I do not have this experience
 

Do you have experience providing substance abuse counseling services to clients for drug and/or alcohol
issues?

6-12 months experience
13-24 months experience
25-36 months experience
I do not have this experience
 

Do you have experience in a locked psychiatric facility? This can include psychiatric hospitals or Institutes for Mental Disorder (IMD) facilities?

6-12 months experience
13-24 months experience
25-36 months experience
I do not have any experience in a locked psychiatric facility
 

Do you have experience providing mental health and/or substance abuse services in criminal justice settings such as juvenile hall, California Youth Authority, county jail, prison, or program serving adult or youth probationers?

6-12 months experience
13-24 months experience
25-36 months experience
I do not have experience in this type of setting
 

Do you have experience providing Residential Mental Health Treatment? This includes mental health and/or substance abuse settings, such as group homes, sub-acute residential treatment, social rehabilitation, and dual diagnosis (mental health and substance abuse) residential programs (Does not include residential services for developmentally delayed population; for persons applying for drug and alcohol services may include substance abuse treatment settings)?

6-12 months experience
13-24 months experience
25-36 months experience
I do not have experience in this type of setting
 

Do you have experience providing mental health and/or substance abuse services in community settings, such as client’s home, park, etc. (not in the office or clinic setting)?

6-12 months experience
13-24 months experience
25-36 months experience
I do not have experience providing these services away from an office or clinic setting
 

Do you have experience providing mental health and/or substance abuse services in a school setting, community based organization and/or primary care physician office and/or primary health clinic?

6-12 months experience
13-24 months experience
25-36 months experience
I do not have experience in this type of setting
 

Do you have experience placing hostile, distressed and/or acutely psychiatrically symptomatic persons on a 5150/5585 hold and/or assessing hostile, distressed and/or acutely psychiatrically symptomatic person to determine if they need to be psychiatrically hospitalized?

6-12 months experience
13-24 months experience
25-36 months experience
I do not have experience assessing for psychiatric hospitalization
 

Do you have experience conducting and documenting psychosocial evaluations/assessments including recommending Diagnostic and Statistical Manual (DSM) diagnosis? 

6-12 months experience
13-24 months experience
25-36 months experience
I do not have this experience
 

Do you have experience providing mental health and/or substance abuse services with co-workers from different disciplines (psychiatrists, consumer employees, therapists, case managers, social workers, public guardians, probation officers, teachers, school psychologists, law enforcement officers, and/or different agencies)? 

6-12 months experience
13-24 months experience
25-36 months experience
I do not have experience with multidisciplinary team collaboration
 

All the information provided is true and accurate. I understand that misrepresenting my experience will result in automatic disqualification from the recruitment process. 

Yes
No