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#1018-RS2014-01
Supplemental Questionnaire

Last Name
First Name
1

To qualify, applicants must have graduated with a master's degree or doctorate from an accredited college or university.  Please indicate if you possess a master's degree in one of the following disciplines:

Master's - Social Work
Master's - Counseling
Master's - Psychology
Doctorate - Psychology
Other
None
1a

Provide the name of the accredited college/university attended.

If you selected "other" in question #1, include the discipline/field for which you obtained your Master's degree.

2

Candidates must possess and maintain current and active licensure from the State of California with one of the following:

Licensed Clinical Social Worker (LCSW)
Marriage and Family Therapist (MFT)
Licensed Professional Clinical Counselor (LPCC)
Licensed Psychologist issued by the California Board of Psychology
Other (specify in question #2a)
None
2a

Provide your license number and expiration date. (A copy of your license must be submitted with your employment application)

3

Describe your two years of full-time paid progressively responsible licensed casework experience as a LCSW, MFT, LPCC, or Psychologist which included counseling or therapy in a clinical or treatment setting. Include the employer, dates of employment, and the specific work performed.

3a

Describe your supervisory experience as a licensed clinician. Include the number of employees supervised and your scope of responsibility.

4

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

5

Positions to be filled may require working rotating shifts (nights, weekends, and holidays). If these positions become available, are you interested in being referred for hiring consideration? 

Yes No