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Supplemental Questionnaire

Last Name
First Name


2932 Senior Behavioral Health Clinician

Supplemental Questionnaire

All applicants are required to complete the Supplemental Questionnaire (SQ) as part of the online application process.  The purpose of the Supplemental Questionnaire is to determine whether applicants possess the minimum qualifications for this 2932 Senior Behavioral Health Clinician position.  This information should be consistent with your application (i.e., must be included in the Education and Training and Employment Record sections) and is subject to verification.


Do you possess a current and valid Licensed Clinical Social Worker (LCSW), Marriage and Family Therapist (MFT), or Licensed Professional ClinicalCounselor (LPCC) license issued by the California Board of Behavioral Sciences?


Yes No

If you answered Yes to the above question please provide the license type (LCSW, MFT, or LPCC), your license/registration number, and the expiration date of the license. If you answered No please type N/A.


Do you possess at least two (2) years (equivalent to 4000 hours) of verifiable post-Master’s psychiatric Marriage, Family and Child Counselor (MFCC), Marriage, Family Therapist (MFT), Clinical Social Worker (LCSW) or Professional Clinical Counselor (LPCC) experience in a psychiatric or medical setting?

Yes No

Do you claim bilingual fluency in Cantonese and English?

Yes No

Are you willing and able to work part-time (32 hours/week)?

Yes No

CERTIFICATION: I hereby certify that all information is true and based on my education, training, skills, and experience. I understand that any false or incorrect statement may result in my disqualification of the selection process for this position and/or dismissal from employment with the City and County of San Francisco. I also understand and agree that any information provided is subject to verification.