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#17-002007-0008
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.***


1

Do you possess a current license as a Certified Social Worker, Clinical (LCSW-C) from the Maryland Board of Social Work Examiners? 

Yes No
2

Please describe your experience providing clinical and therapeutic social work services to clients requiring rehabilitate counseling or forensic social work services, including your experience completing assessments, formulating diagnostic impressions, treating mental disorders and other conditions or providing psychotherapy as a Certified Social Worker, Clinical
(LCSW-C). Also, identify from your application where you gained this experience. Please provide the name of the employer and dates of employment and hours per week worked. If you do not have this experience, please enter N/A

3

Please describe your experience supervising lower level social workers providing clinical and therapeutic social work to clients. Also, identify from your application where you gained this experience. Please provide the name of the employer and dates of employment and hours per week worked. If you do not have this experience, please enter N/A

4

Do you have one year of experience providing Mental Health treatment to youth?

Yes No
5

If you answered yes to question 4., Please describe your experience providing mental health treatment to youth. Also, identify from your application where you gained this experience. Please provide the name of the employer and dates of employment and hours per week worked. If you do not have this experience, please enter N/A.

6

Please describe your experience providing behavioral health services to troubled adolescents and their families along with your experience coordinating or leading an adolescent/youth focused behavioral health team within the criminal justice field. Also, identify from your application where you gained this experience. Please provide the name of the employer and dates of employment and hours per week worked. If you do not have this experience, please enter N/A


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