Official SealSan Joaquin County Human Resources Division


#0722-RS2012-AC
Supplemental Questionnaire

Last Name
First Name

 

Please complete the following supplemental questionnaire. This questionnaire is considered an extension of your employment application and will be reviewed to help assess your qualifications. Resumes are not accepted in lieu of completing this questionnaire.


1a.

License

PATTERN I

To qualify under this pattern, you must possess and maintain a valid license as a Licensed Clinical Social Worker (LCSW), Marriage and Family Therapist (MFT), or Licensed Professional Clinical Counselor (LPCC) issued by the California Board of Behavioral Sciences.  Please select from the following the current and active registration you possess:

Licensed Clincial Social Worker (LCSW)
Marriage and Family Therapist (MFT)
Licensed Professional Clinical Counselor (LPCC)
 

Provide your registration number and expiration date.  (Note:  Applications pending registration will not be accepted as qualifying)

1b.

PATTERN II

To qualify under this pattern, you must possess and maintain a valid California license as a Psychologist issued by the California Board of Psychology.  Please provide your license number and expiration date.


 

THE FOLLOWING IS REQUIRED FOR BOTH PATTERNS.


2.

Graduation from an accredited university with a master's or doctorate degree in social work, counseling, psychology or other course of study acceptable to the State of California Board of Behavioral Sciences toward licensure as a Licensed Clinical Social Worker (LCSW), Marriage and Family Therapist (MFT), Licensed Professional Clinical Counselor (LPCC), or Psychology is required.  Please provide the following information:

  • Name of college or university from which you graduated
  • Degree obtained
  • Major
3.

Candidates must possess and maintain a valid California driver's license.  Provide your license number and expiration date.

4.

In addition to full time vacancies, this list may also be utilized to fill part time opportunities in the department. Please indicate if you are willing to accept part time opportunities. Accepting part time employment will not exclude you from other full time opportunities.

Yes No