Official SealSan Joaquin County Human Resources Division


#0518-RS2013-AC
Supplemental Questionnaire

Last Name
First Name
1.

YOU MUST MEET ONE OF THE FOLLOWING MINIMUM QUALIFICATIONS

 

EITHER PATTERN I

 

Special Requirement:  Must possess and maintain 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.

 

Please indicate which license you possess, license number and date of issuance in the space provided below.

2.

OR PATTERN II

 

Special Requirement:  Must possess and maintain a valid license as a Psychologist issued by the California Board of Psychology.

 

Please provide license number and date of issuance in the space provided below.

3A.

AND FOR BOTH PATTERNS

 

Education:  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 towards licensure as a Licensed Clinical Social Worker (LCSW), Marriage and Family Therapist (MFT), Licensed Professional Clinical Counselor (LPCC), or Psychologist.

 

Please list the name of the university you attended, the degree completed and course of study in the space provided below.

3B.

Experience:  One year of progressively responsible licensed casework experience as an LCSW, MFT, LPCC or Psychologist, which included counseling or therapy in a clinical or treatment setting.

 

Please list the employer, job title, dates of employment, and duties performed that meet this requirement in the space provided below.

3C.

License:  Must possess and maintain a valid California driver’s license.

 

Please list your driver''s license number and expiration date in the space provided below.