Official SealSan Joaquin County Human Resources Division


#1121-RS2011-AC
Supplemental Questionnaire

Last Name
First Name
1.

Did you graduate from an accredited college or university with a master's degree in social work, counseling, psychology or related field?

Yes No
 

Please provide the following information about your master's degree:

  • College/University attended
  • Major
2.

Did you graduate from an accredited college or university with a doctorate in Psychology?

Yes No
3.

Must be eligible for waiver of licensing requirements for a Licensed Clinical Social Worker (LCSW) and Marriage and Family and Therapist (MFT) or Psychologist set by the State of California Welfare and Institutions Code, Section 5600.2.  You must be registered with the California Board of Behavioral Health. 

What is is your MFT Intern # or ASW (Associate Social Worker)#? 

4.

If you possess a valid California driver's license, please provide license number and expiration date: