Official SealSan Joaquin County Human Resources Division


#0122-RS2014-AC
Supplemental Questionnaire

Last Name
First Name
1.

PATTERN I

Do you possess a valid license as a Licensed Clinical Social Worker (LCSW), a Marriage and Family Therapist (MFT), or a Licensed Professional Clinical Counselor (LPCC) issued by the California Board of Behavioral Sciences?

Yes No
1A.

If you answered "Yes" to the question above, please list the type of license you have  and provide your license number and expiration date in space below.

2.

PATTERN II

Do you possess a valid license as a Psychologist issued by the California Board of Psychology?

Yes No
2A.

If you answered "Yes" to the question above, please provide your license number and expiration date in the space below.


 

FOR BOTH PATTERNS


3.

To qualify, applicants must have graduated with a master's degree or doctorate from an accredited college or university.  Please indicate if you possess a master's degree in one of the following disciplines:

Master's - Social Work
Master's - Counseling
Master's - Psychology
Doctorate - Psychology
Other
None
3A.

Provide the name of the accredited college/university attended.

If you selected "other" in question #1, include the discipline/field for which you obtained your Master's degree.

4.

Do you have at least two (2) years of full-time paid progressively responsible licensed casework experience as an LCSW, MFT, LPCC or Psychologist, which included counseling or therapy in a clinical or treatment setting?

Yes No
4A.

Describe your two years of full-time paid progressively responsible licensed casework experience as a LCSW, MFT, LPCC, or Psychologist which included counseling or therapy in a clinical or treatment setting. Include the employer, dates of employment, and the specific work performed.

5.

Do you have at least one (1) year of full-time paid supervisory experience as a as a Licensed Clinical Social Worker (LCSW), Marriage and Family Therapist (MFT), Licensed Professional Clinical Counselor (LPCC), or Psychologist?

Yes No
5A.

Describe your supervisory experience as a licensed clinician. Include the number of employees supervised and your scope of responsibility.

6.

Candidates must possess and maintain a valid California Driver's License.  Provide your valid California driver's license number and expiration date.

7.

Positions to be filled may require working rotating shifts (nights, weekends, and holidays). If these positions become available, are you interested in being referred for hiring consideration? 

Yes No