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Human Resources Department
#22-333190-01


Supplemental Questionnaire

Last Name First Name
 

 

This Supplemental Questionnaire will be used to determine applicants’ qualifications for this position and assess an applicant’s ability to advance in the recruitment process; therefore, applicants are encouraged to answer all questions thoroughly and completely.  Omitted information will not be considered or assumed.  Applicants who have no experience in a specific area are recommended to state "no experience in this area" instead of leaving the space blank.

Please note that the experience in your answers must be reflected in your employment history.


1.

Do you possess a current license issued by the State of California Board of Behavioral Science Examiners as a Marriage and Family Therapist (MFT)?

Yes No
 

Do you possess a current license issued by the State of California Board of Behavioral Science Examiners as a Licensed Clinical Social Worker (LCSW)?

 

Yes No
 

If you do not possess either a Marriage and Family Therapist or a Clinical Social Worker license, do you possess an equivalent license approved by the California Board of Behavioral Sciences?

Yes No
 

If yes, please indicate your license below:

2.

Please select all the areas that you have one or more years of clinical experience.

Adult
Outpatient
Drug and Alcohol
Social Services
Court Services
Juvenile Justice
Children
Inpatient
Crisis
School
Grief or Hospice
Probation
Residential Treatment
Disaster Relief
Conservatorship
Family
Custody Services
Working with Homeless Population
3.

Select your experience(s) with treating and/or counseling in any of the follow areas:

Client - centered group and individual counseling
Family systems
Crisis Intervention
Adult Mental Health
Recreational Therapy
Individual Therapy
Experience with psychiatry clients
Experience working with Primary Care Physicians
Cognitive Behavioral Therapy
Trauma Focused Treatment
Brief Treatment

4.

Do you have experience using the following psychosocial techniques and/or guidelines?


 

Motivational Interviewing

Yes No
 

Cognitive Behavior Therapy

Yes No
 

Dialectical Behavior Therapy

Yes No
 

Eye Movement Desensitization Reprocessing Therapy

Yes No
 

Assertive Community Treatment

Yes No
 

American Society of Addiction Medicine Criteria for Assessment

Yes No

5.

Does your multi-disciplinary team experience include working with any of the following?


 

Community-based services

Yes No
 

County Behavioral Health

Yes No
 

County Child Welfare Services

Yes No

6.

Do you have experience working in a community-based agency or county mental health setting serving the following populations?


 

Children

Yes No
 

Adults

Yes No
 

Juvenile Sex Offenders

Yes No
 

Dual Diagnosed

Yes No
 

Corrections and/or Probation Services

Yes No
7.

Some positions require bilingual skills in Spanish.  Applicants who indicate bilingual skills in will be required to demonstrate proficiency in speaking, reading and writing in Spanish.      

Are you proficient in speaking, reading and writing Spanish?   

                 

Yes No
8.

Some positions require bilingual skills in Tagalog.  Applicants who indicate they have bilingual skills will be required to demonstrate proficiency in speaking, reading and writing in Tagalog.      

Are you proficient in speaking, reading and writing Tagalog?  

Yes No