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#15-001567-0004
Supplemental Questionnaire

Last Name
First Name

 

Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval. 


1.

Do you have a license from the Maryland State Board of Professional Counselors and Therapists as a Certified Professional Counselor-Alcohol and Drug OR Licensed Clinical Alcohol and Drug Counselor?

If you do have the appropriate license, then please submit a copy of your license with your application.

Yes No
2.

If you possess a LCADC, then do you have at least 1 year of experience treating juveniles with co-occurring mental health and substance use disorder?  If yes, then please describe your experience in the field below.


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