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Santa Cruz County Personnel Department
#24-NP5-CC


Supplemental Questionnaire

Last Name First Name
 
1

Do you contain any of the following: 

Four years full-time experience in a recognized public or private agency providing mental health counseling*, substance abuse counseling, psychosocial rehabilitation, or case management services to individuals with mental illness, substance use disorders, or emotional disturbance.
BA Degree from a college or university in counseling, psychology, other mental health related field AND three years full-time experience in a recognized public or private agency providing mental health counseling*, substance abuse counseling, psycho-social assessment, or case management services to individuals with mental illness, substance use disorders, or emotional disturbance.
A one-year Master's Degree from an accredited college or university in Marriage, Family and Child Counseling, Social Work, Clinical Psychology, Counseling, Psychiatric Nursing, Psychology, or closely related behavioral science field AND two years full-time experience in a recognized public or private agency providing mental health counseling*, substance abuse counseling, psycho-social assessment, or case management services to mentally ill, substance abusing, or emotionally disturbed individuals.
A two-year master’s degree from an accredited college or university in Marriage, Family and Child Counseling, Social Work, Clinical Psychology, Counseling, Psychiatric Nursing, Psychology, or closely related behavioral science field (with a focus in counseling methods or techniques).
None of these apply to me.
2

Are you eligible for or do you currently possess an Associate Clinical Social Worker or Marriage and Family Therapist License? 

Yes
No
3

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
4

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
5

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
6

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
7

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
8

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
9

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
10

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
11

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