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#17-001565-0001
Supplemental Questionnaire

Last Name
First Name
1.

Describe your experience provding substance abuse counseling to youth.  Include place of employment, dates and job duties.  If no experience, indicate N/A.

2.

Describe your experience creating treatment plans.  Include place of employment, dates and job duties.  If no experience, indicate N/A.

3.

Describe your experience performing intakes and assessments for admission to alcohol and drug treatment programs.  Include place of employment, dates and job duties.  If no experience, indicate N/A.

4.

Describe your case management experience.  Include place of employment, dates and job duties.  If no experience, indicate N/A.

5.

Describe your experience in crisis intervention.  Include place of employment, dates and job duties.  If no experience, indicate N/A.


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