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Human Resources Department
#22-333180-01


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.


 

Do you have verification of acceptance by the State of California Board of Behavioral Science Examiners as a candidate for licensure (registered intern/associate) as a Marriage and Family Therapist Intern (MFTI)?

Yes No
 

Do you have verification of acceptance by the State of California Board of Behavioral Science Examiners as a candidate for licensure (registered intern/associate) as a Associate Licensed Clinical Social Worker (ALCSW)?

Yes No
 

Do you have verification of acceptance by the State of California Board of Behavioral Science Examiners as a candidate for licensure (registered intern/associate) as a Licensed Professional Clinical Counselor(LPCC)?

Yes No
 

Do you have verification of acceptance by the State of California Board of Behavioral Science Examiners as as a candidate for licensure (registered intern/associate) in any other equivalent license approved by the California Board of Behavioral Science?

Yes No
 

If yes, please indicate your license below:

1

Describe your experience with providing or supporting mental health services to severely, persistently mentally ill adults.

I have less than 1 year of experience
I have 1 - 2 years of experience
I have 2 - 4 years of experience
I have more than 4 years of experience
I have no experience
2

Please describe your familiarity/experience working in a community based mental health agency or county mental health setting.

I have less than 1 year of experience
I have 1 - 2 years of experience
I have 2 - 4 years of experience
I have more than 4 years of experience
I have no experience
3

Please select the option that best describes your experience working with multi-disciplinary teams.

I have less than 1 year of experience
I have 1 - 2 years of experience
I have 2 - 4 years of experience
I have more than 4 years of experience
I have no experience
4

Please select the option that best describes your experience working with youth who have experienced traumatic life events or who have been involved with multiple agencies such as child welfare, juvenile justice, special education services.

I have less than 1 year of experience
I have 1 - 2 years of experience
I have 2 - 4 years of experience
I have more than 4 years of experience
I have no experience
5

Proof of the required Master's degree. All applicants must submit a copy of their degree (verifying the degree, date earned and area of specialization) or transcripts (official/unofficial verifying the student, institution, and date and degree conferred).

Verification of acceptance by the California State Board of Behavioral Science Examiners as a candidate for licensure (registered intern/associate) as either a Marriage and Family Therapist Intern (MFTI) or Associate Licensed Clinical Social Worker (ALCSW) or any other equivalent licensed approved by the California Board of Behavioral Science.

I will be submitting all the above in the following manner:

Uploading to my employment application prior to submittal
Emailing to recruitment@solanocounty.com
Faxing to (707) 784-3424
6

Some positions may require bilingual skills. Applicants who indicate bilingual skills on their application may be required to demonstrate proficiency in speaking, reading, and writing in the language indicated.

Are you proficient in speaking, reading, and writing any of the following languages?

Spanish
Tagalog
Vietnamese
None of the above