Official SealSan Joaquin County Human Resources Division


#0722-HS2000-EX
Supplemental Questionnaire

Last Name
First Name
 

 

Please provide your California license number to one of the following: 

  1. Licensed Clinical Social Worker (LCSW), a Marriage and Family Therapist (MFT), or a Licensed Professional Clinical Counselor (LPCC) issued by the California Board of Behavioral Sciences (CBBS).
  2. A Psychologist issued by the California Board of Psychology.
  3. A Physician, issued by the Medical Board of California (including certification by the American Board of Psychiatry and Neurology).
  4. Registered Nurse issued by the California Board of Registered Nursing (BRN), and current listing with the BRN as a Psychiatric/Mental Health Nurse.