Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name


Please submit responses to the following questions along with your employment application for the Mental Health Clinician III to the San Joaquin County Human Resources Division.

A copy of the required license must be submitted to Human Resources at the time of application.  It may be sent via email to, attached when submitting a resume, by fax to (209) 468-0508, or mailed to the Human Resources Department.


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 (MFT), Licensed Professional Clinical Counselor (LPCC), or Psychologist?

Yes No

If you answered yes, please provide the following information: Degree type, discipline/emphasis, and university attended.


Describe at least one year 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.


In order to qualify, applicants must possess and maintain a valid California license of one of the following:

Marriage and Family Therapist (MFT) issued by the California Board of Behavioral Sciences (BBS)
Licensed Professional Clinical Counselor (LPCC) issued by the California Board of Behavioral Sciences (BBS)
Licensed Clinical Social Worker (LCSW) by the California Board of Behavioral Sciences
Licensed Psychologist issued by the California Board of Psychology
none of the above

Please provide your California driver's license number and expiration date (mm/dd/yyyy).

Note: If selected, the license must remain valid during employment.