Official SealSan Joaquin County Human Resources Division


#1025-RS2012-AC
Supplemental Questionnaire

Last Name
First Name
1.

PATTERN I

Do you possess a valid license as a 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?
Yes No
1a.

License Number AND Expiration Date
2.

PATTERN II

Do you possess a valid license as a Psychologist issued by the California Board of Psychology?
Yes No
2a.

If you answered Yes, please provide your license number and expiration date. 
3.

Have you graduated 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 towards licensure as a Licensed Clinical Social Worker (LCSW), Marriage and Family Therapist (MFTI), Licensed Professional Clinical Counselor (LPCC), or Psychologist? If so, please ensure you have filled out the education portion of the application in detail.
Yes No
4.

Do you possess a valid California Class C driver's license?
Yes No
4a.

License Number AND Expiration Date