North Carolina Marriage and Family Therapy Licensure Board: Who Should Complete This Application

NORTH CAROLINA MARRIAGE AND FAMILY THERAPY LICENSURE BOARD
Mailing Address: Post Office Box 37669, Raleigh, NC 27627 Phone: (919) 469-8081 Fax: (919) 336-5156 Email: ncmftlb@nc.rr.com Web: www.nclmft.org
APPLICATION FOR NORTH CAROLINA LICENSED MARRIAGE AND FAMILY THERAPIST ASSOCIATE (LMFTA)
WHO SHOULD COMPLETE THIS APPLICATION
Complete this application only if you have met ALL of the following criteria. Academic: Possesses a minimum of a masters degree from a recognized educational institution in the field of marriage and family therapy, or a related degree as defined in NC Statute 90-270.47 with post qualifying degree training which is the equivalent in content and quality as defined in the rules of the Board. The transcript verifying your masters or doctors degree must include the degree title and date of conferral. Do not submit the LMFTA application until your degree has been conferred. Experience: A signed supervision agreement with an approved supervisor (AAMFT Approved Supervisor) must accompany all LMFTA applications. The LMFTA has up to three years to acquire the clinical and approved supervision hours required for transition to licensure as an LMFT. There is a requirement of at least 1500 hours of supervised (under an AAMFT Approved Supervisor) clinical experience in the practice of marriage and family therapy, not more than 500 hours of which were obtained while the applicant was a student in his/her qualifying degree program and at least 1000 of which were obtained after the degree was granted. A minimum of 200 supervision hours is required. The LMFTA is not renewable and is valid for a period of three years from date of issue. Supervision reports denoting the hours earned thus far may be submitted at the time of LMFTA application. Examination: LMFTA applicants must have passed the National MFT Examination or have taken the exam and the score report is pending BEFORE submitting the LMFTA application. Applicants who have already passed the national exam in another state must request a copy of their official national exam report to be mailed directly the board office from the testing service using the score transfer form included in this packet.
RESPONSIBILITY OF THE NC MFT LICENSURE BOARD

The North Carolina Marriage and Family Therapy Licensure Boards mission is to ensure that the public is protected from unprofessional, unauthorized and unqualified individuals practicing marriage and family therapy, and the unprofessional, improper, unauthorized and unqualified use of certain titles used by person who practice marriage and family therapy.
QUESTIONS
If AFTER reading the application you have specific questions regarding the application process, please contact the Board via email at ncmftlb@nc.rr.com. Do not contact individual Board members regarding your application as they cannot discuss pending items. All applications must be submitted directly to the Board office and are reviewed by the entire Board.
Application - LMFT - Effective August 15, 2010
APPLICATION PROCESS
If you have not passed or taken the National MFT Examination do not submit this application. You should first refer to the examination requirements and apply to take the exam. All applicants for licensure must complete this packet in its entirety unless otherwise indicated and submit it via U.S. Postal Service delivery with the required $200 application fee (check or money order only) to: NC MFT Licensure Board, PO Box 37669, Raleigh, NC 27627. Do not fax or email this application. Only original, mailed, notarized applications will be accepted. Failure to complete all required parts of the application will delay its review. Your signature must be notarized by a Notary Public. Incomplete applications will be returned to the applicant. If an application is returned to the applicant a second time as incomplete, the Board may impose an additional $10 processing fee. No action, processing or approval of your application will take place until all three requirements (academic, supervision agreement and passing the National MFT Examination) have been demonstrated and accepted. You may submit this application once you have sat for the exam, but it will not be processed until verification that you have passed the exam has been received. If you sat for exam based on approval to take the exam by the NC MFT Licensure Board, then your scores will be automatically reported to the Board. If you provide an email address, we will send acknowledgment of receipt of this application. Please carefully read the information before initiating any inquires. This packet contains all the information and forms needed to make application. Keep in mind that the Board meets four times a year. When submitting your application, please include ALL necessary documents in one package (excluding forms designated to be sent directly to the Board). Do not send documents separately. Be sure the endorsements, supervision agreement and any supervision reports are in sealed envelopes with the signature of the endorsers and supervisors over the sealed closure. AN APPLICATION WILL NOT BE SCHEDULED FOR BOARD REVIEW UNTIL ALL REQUIRED DOCUMENTS AND FEES HAVE BEEN RECEIVED. Prior to mailing this application, make copies of all your documents with the exception of any sealed documents. All materials, once received, become the property of the Board and copies are not returned or available to applicants.
NC STATUTES AND RULES

In addition to the information in this application packet, you should carefully review the Statutes and Administrative Rules ( published at www.nclmft.org ) governing the practice of marriage and family therapy in North Carolina.
CODE OF ETHICS
The Board has adopted the code of ethical principles published as the AAMFT CODE OF ETHICAL PRINCIPLES FOR MARRIAGE AND FAMILY THERAPISTS The current code is published on the AAMFTs website (www.aamft.org).
FOREIGN EDUCATION
For the Board to consider education completed outside the United States, documentation must be received which verifies the institution at which the education was completed was equivalent to an accredited U.S. institution and the coursework must meet the content and credit hour requirement for graduate level coursework in the United States. It is the applicants responsibility to obtain an evaluation from a recognized educational evaluation service that documents the acceptability of the coursework. The Board office must receive an original evaluation mailed directly from the educational evaluation service. All forms must be completed in English. A certified translator not related to the applicant must translate foreign language documents into English.
GENERAL INFORMATION
North Carolina residency is not required to apply for licensure. Complete all forms by printing in black ink or typing. Illegible applications will not be reviewed. Incomplete or incorrectly submitted applications will not be reviewed and may be returned to the applicant. All forms must be original, including signatures. Course of study is defined as a 45 semester hour graduate program which consists of the coursework listed in this application. Applicants are not licensed or authorized to practice MFT in the State of North Carolina unless they are exempt under NC Statutes (see www.nclmft.org laws and rules) until they receive official notification directly from the NC MFT Licensure Board. You and/or your employer should be familiar with North Carolina Statutes and determine if an exemption applies. NC does not issue temporary licenses. The Board will not act as your agent in gathering information or supporting documents. Official transcripts of all graduate academic work must be sent directly to the Board office by the issuing institution. Copies submitted by the applicant will not be accepted, even if they are in sealed envelopes from the school. It is your responsibility to notify the licensure board in writing if the answer to any application question changes. Applications must be received (postmarked) by the stated deadline date(s) on the calendar posted at www.nclmft.org in order to be considered at the next available board meeting. Complete applications received (postmarked) after the stated deadline date will be transferred to the next scheduled board meeting. You will be notified of your status by letter following the Boards review. Notifications are mailed within 10 business days after the Board meeting. Refer to www.nclmft.org for a calendar of board meetings deadline and decision notification dates. Application fees are non-refundable and may be paid in the form of your personal check or money order, made payable to the NC MFT Licensure Board. An application will not be considered until the fee is paid. Returned check fee is $25. Applications will be held open for submission of supplementary information for a period of two years for from the date of the original submission. After that time, a new application and fee will be required. Retain pages 1,2,3, and 13 for your records. Do not submit these pages with the application.
APPLICATION FOR LICENSED MARRIAGE AND FAMILY THERAPIST ASSOCIATE (LMFTA)

APPLICANT GENERAL INFORMATION
(Print name exactly as you wish it to appear on our license.)
Name: _______________________________________________________________________
(last) (first) (middle)
(You must promptly notify the Board of any address or name change.)
Professional Address Send correspondence here Do not publish address _____________________________________________________________________________

(number and street) (apt. number)
_____________________________________________________________________________
(city) (state) (zip)
_____________________________________________________________________________
(phone including area code) (email - optional) (website optional)
Home Address Send correspondence here Do not publish address _____________________________________________________________________________

(number and street) (apt. number)
_____________________________________________________________________________
(city) (state) (zip)
_____________________________________________________________________________
(phone including area code) (email - optional)
Have you ever been known by any other names?
YES
NO
If YES list name(s): __________________________________________________________ Date of Birth: _____________

(month/day/year)
NC County of Residence ____________________________

(if current NC resident)
Social Security Number_____________________________

DO NOT WRITE IN THIS SPACE OFFICE USE ONLY
(Postmarked Date / Check # / Check Amount
Do Not Staple
Attach Securely In This Space a 2 x 2 Clear, Passport Style Photo Taken Within The Past Year. Head and Shoulders Only
Name: _______________________________________________________________________ (last) (first) (middle) APPLICANT LICENSURE STATUS

Do you hold or have you ever held a license to practice MFT or any counseling-related professions in any state, U.S. territory, or foreign country. YES NO If YES, supply the following information: Attach an additional page if necessary
State, Territory, or Country
Title of License
License Number
Date Issued
Date Expired
Do you any applications for licensure in a counseling-related profession currently pending in any state, U.S. territory, or foreign country. YES NO If YES, list all pending applications and the issuing state, territory or foreign country. Attach an additional page if necessary
State, Territory, or Country
Title of License Application
Date Applied
APPLICANT PROFESSIONAL HISTORY Dates of Experience Place of Employment (Name, City State) Supervisor (if applicable)
APPLICANT EDUCATION
All applicants must complete the information below. Official transcripts of all graduate academic work must be sent directly to the Board office by the issuing institution. Do not send undergraduate transcripts. If you completed additional courses to meet the required credits for coursework after your qualifying Masters or Doctoral degree, official sealed transcripts from those institutions must be sent directly to the Board office by the issuing institution.
Education College/University Degree Major Date Conferred Credit Hours Received (Optional_ COAMFTE or CACREP MFT Accredited? (Y or N)
Masters
Post Masters Coursework Doctoral Degree

Name: _______________________________________________________________________ (last) (first) (middle) APPLICANT GENERAL AND ETHICAL HISTORY 1. Have you ever been convicted or found guilty or pled nolo contendere of a crime in any jurisdiction, including a military court-martial? YES NO If YES, attach an explanation which provides the date, jurisdiction, offense, and disposition. Attach a certified copy of the disposition. 2. Have you ever been disciplined or denied licensure by any state or national licensing, certifying or regulatory entity? YES NO If YES, attach an explanation which includes the jurisdiction, nature of discipline, board or organization name, and nature of discipline. 3. Have you ever been convicted of any violation of Federal or state law related to the practice of marriage and family therapy or any counseling profession? YES NO If YES, attach an explanation. 4. Is there currently pending, in any jurisdiction, a complaint against your professional conduct or competency in a marriage and family therapy or counseling related profession? YES NO If YES, attach an explanation. 5. Have you ever been denied marriage and family therapy or counseling related license or the renewal thereof in any state? YES NO If YES, attach an explanation. 6. Have you ever been involved in, reprimanded for or disciplined by an employer or educational institution for misconduct including acts of dishonesty, fraud or deceit; lying or misrepresentation of credentials; academic misconduct including acts such as cheating or plagiarism; theft; or sexual harassment? YES NO If YES, attach an explanation. APPLICANT ENDORSERS/REFERENCES
List names here and send an endorsement form (page 10) to each endorser. Individuals completing supervisor forms cannot serve as endorsers.
APPLICANT EXAMINATION VERIFICATION Check One:

I certify that I have passed the National MFT Examination. I certify that I took the National MFT Examination on (insert date) _______________ State in which examination was taken ____________________________
If your exam score was not reported/will not be reported to the NC MFT Licensure Board you should complete the Score Transfer form located at www.nclmft.org under the Examination section. Your licensure application cannot be reviewed until this report is received.
Exam Date_____________________ Exam Score___________________

Name: _______________________________________________________________________ (last) (first) (middle) APPLICANT COURSEWORK (Type or print in black ink)
ALL APPLICANTS MUST COMPLETE THE FOLLOWING COURSEWORK SECTION AND PROVIDE REQUESTED DOCUMENTATION. INCOMPLETE APPLICATIONS WILLN NOT BE PROCESSED.
All applicants must have an official sealed transcript sent directly from institution(s) in order to have their application evaluated. Coursework descriptions for the courses listed below must be submitted (attach to coursework pages) and must be from the catalogue for the year in which the courses were taken (photocopies acceptable). Send only pages germane to your application and highlight courses in the catalogue that should be referenced for your application review. Do not list a course under more than one category. Course titles should be consistent with the course title on the transcript.
COURSE TITLE (May abbreviate) COURSE NUMBER SEMESTER or QUARTER CREDIT HOURS INSTITUTION WHERE COURSE WAS TAKEN
COURSEWORK CATEGORIES
GENERAL FAMILY STUDIES

Minimum 6 semester or 9 quarter hours May include courses in marriage, family relations, child development, family sociology, or other courses where family content is evident
MARRIAGE AND FAMILY THERAPY THEORY

Minimum 6 semester or 9 quarter hours Specific and extensive content in systems theory or other theoretical approaches in MFT
PSYCHOPATHOLOGY/ ABNORMAL BEHAVIOR

Minimum 3 semester or 5 quarter hours
Name: _______________________________________________________________________ (last) (first) (middle) APPLICANT COURSEWORK (Type or print in black ink)
COURSEWORK CATEGORIES COURSE TITLE (May abbreviate) COURSE NUMBER SEMESTER OR QUARTER CREDIT HOURS INSTITUTION WHERE COURSE WAS TAKEN
THEORIES OF PERSONALITY
CLINICAL PRACTICUM
Minimum 9 semester or 14 quarter hours Course content must include client contact and clinical supervision with individuals, couples and families in a clinical setting. Minimum of 120 hours of face to face contact. Minimum of 24 hours of supervision by an AAMFT Approved Supervisor
ADDITIONAL CORE COURSEWORK

Coursework should be appropriate to the specialty in which the qualifying degree is granted.
AFFIDAVIT
(ALL APPLICATIONS ARE SUBJECT TO A CRIMINAL BACKGROUND CHECK.) APPLICANT I affirm that the information I am submitting is true and correct to the best of my knowledge and belief. I authorize the North Carolina Marriage and Family Therapy Licensure Board to communicate with any person or entity in connection with this or any subsequent application filed with the Board. I will hold the Board, its members, officers and agents, free from any damage or complaint by reason of any action they, or any of them, may take in connection with this request. I have reviewed a copy of the North Carolina Statutes and Administrative Rules and the AAMFT Code of Ethics. I have reviewed the instructions describing the application process. I am of good moral character and have not engaged in any practice or conduct that would be a ground for denial, revocation, or suspension of a license under G.S. 90-270.60. I am the person who executed this application. I have not suppressed information that might affect this application. I will adhere to the ethical standards of conduct in Marriage and Family Therapy as adopted by the North Carolina Marriage and Family Therapy Licensure Board, i.e. AAMFT Code of Ethics. I understand that the fee submitted with this application is not refundable. I have read and understood this affidavit. Name: (please print) ___________________________________________________________ ____________________________________________________________________________ Signature Date NOTARY Name: (please print) ___________________________________________________________ ____________________________________________________________________________ Signature Date Sworn to me this ________day of _________________, _______ State of ________________ County of__________________ (Seal)
NORTH CAROLINA MARRIAGE AND FAMILY THERAPY LICENSURE BOARD PROFESSIONAL ENDORSEMENT
Instructions to the Applicant: Print a copy of the Professional Endorsement form for each of the required three professional (not personal) references who are familiar with your current work. Type and print the name of the endorser and your name where indicated. Send a form to each endorser or refer him/her to where the form is found on the Boards website with instructions to return the completed form to you, the applicant, in a sealed envelope with the endorsers signature over the seal. Forms submitted without the endorsers signature over the seal will not be accepted. Individuals completing supervisor forms cannot serve as endorsers. You may wish to provide a stamped, self-addressed envelope to the endorser. (Please print) To: _______________________________________ Re: _____________________________________ (endorsers name) (applicants name) Instructions to the Endorser: The above-named individual has made application to the NC Marriage and Family Therapy Licensure Board and has listed you as a reference/endorser. Please complete and return this form to the applicant, in a sealed envelope with your signature over the seal. Forms submitted without the endorsers signature over the seal will not be accepted. Faxed copies are not accepted. 1. How long have you known the applicant?
2. What is your professional relationship with the applicant? 3. What is your knowledge of the applicants professional qualifications? (check one) Limited Moderate Thorough 4. To the best of your knowledge, do you find the applicant adheres to legal and ethical standards? Yes No 5. Are you aware of any issues that would impair the individuals ability to practice? Yes No If yes, please explain. Attach separate page. 6. Please note any areas of concern, comments or recommendations to the Board. Attach additional page if required.
_______________________________________
(endorsers name) (type or print)
_______________________________________
(endorsers signature)
Date:______________________ Address___________________________________________________ Email Address:_________________________________ Daytime Phone Number___________________
RETURN FORM TO: the applicant in a sealed envelope with your signature over the seal.
10
SUPERVISION AGREEMENT
Instructions to the Applicant: Type and print the name of the supervisor and your name where indicated. Send the form to supervisor with instructions to return the completed form to you, the applicant, in a sealed envelope with the supervisors signature over the seal. Forms submitted without the supervisors signature over the seal will not be accepted. Faxed copies are not accepted. Applicants may wish to provide a stamped, self-addressed envelope to the supervisor. (Please print)
To: _______________________________________ Re: _____________________________________ (supervisors name) (applicants name)

Instructions to the Supervisor: The above-named individual has made application to the NC Marriage and Family Therapy Licensure Board and has listed you as their supervisor. Please complete and return this form to the applicant, in a sealed envelope with your signature over the seal. Forms submitted without the supervisors signature over the seal will not be accepted. Faxed copies are not accepted.
I can provide evidence of training in marriage and family therapy supervision by one or more of the following designations: I am an AAMFT Approved Supervisor * Approval Date: ________ Expiration Date: ________
I am an AAMFT Supervisory Candidate* * under the supervision of _____________________________________.

(approved Supervisors name) (please print) * If your name is not listed in the Approved Supervisor Directory at www.aamft.org, then you must provide documentation of your status from AAMFT. ** The Board reserves the right to require written verification of the supervisory arrangement of supervisory candidates. My signature attests to the accuracy of (1) my supervisory status; and (2) I have agreed to provide supervision for the above person working toward licensure; and (3) I agree to make quarterly reports to the Board on forms provided to me by the Board; and (4) supervision will be provided in accordance with section .0502 (b & c) of the NC Administrative Code defined as:
Approved ongoing supervision shall focus on the raw data from the supervisee's continuing clinical practice, which shall be available to the supervisor through a combination of direct observation, co-therapy, written clinical notes, and audio and video recordings. None of the following shall be deemed to constitute acceptable approved ongoing supervision: (1) peer supervision, i.e., supervision by a person of equivalent, rather than superior, qualifications, status and experience; (2) supervision by current or former family members or any other persons where the nature of the personal relationship prevents or makes difficult the establishment of a professional relationship; (3) administrative supervision - for example, clinical practice performed under administrative rather than clinical supervision by an institutional director or executive; (4) a primarily didactic process wherein techniques or procedures are taught in a classroom, workshop or seminar; (5) consultation, staff development, or orientation to a field or program, or role-playing of family interrelationships as a substitute for current clinical practice in an appropriate clinical situation.
_______________________________________
(supervisors name) (type or print)
_______________________________________
(supervisors signature)
Date:______________________ Address___________________________________________________ Email Address:_________________________________ Daytime Phone Number___________________
11
CLINICAL AND SUPERVISION HOURS REPORT

Instructions: Type and print the name of the supervisor and your name where indicated. Send the form to each supervisor from whom a report is required (or refer him/her to where the form is found on the Boards website). The supervisor is to return the completed form the applicant, in a sealed envelope with the supervisors signature over the seal. Forms submitted without the supervisors signature over the seal will not be accepted. Faxed copies are not accepted. Applicants may wish to provide a stamped, selfaddressed envelope to the supervisor. All earned hours, including those earned while a student should be reported using this form.
(Please print)
To: _______________________________________ Re: _____________________________________ (supervisors name) (applicants name) Please note: North Carolina only approves supervision from one of the following:
(Check one)
I am an AAMFT Approved Supervisor
Expiration Date: _______________________
If your name is not listed in the Approved Supervisor Directory at www.aamft.org, then you must provide documentation of your status from AAMFT.
I am an AAMFT Supervisory Candidate under the supervision of ______________________.

(approved Supervisors name) (please print) The Board reserves the right to require written verification of the supervisory arrangement of candidates.
My signature attests to the accuracy of (1) my supervisory status;and (2) supervision was provided in accordance with section .0502 (b & c) of the NC Administrative Code defined as:
Approved ongoing supervision shall focus on the raw data from the supervisee's continuing clinical practice, which shall be available to the supervisor through a combination of direct observation, co-therapy, written clinical notes, and audio and video recordings. None of the following shall be deemed to constitute acceptable approved ongoing supervision: (1) peer supervision, i.e., supervision by a person of equivalent, rather than superior, qualifications, status and experience; (2) supervision by current or former family members or any other persons where the nature of the personal relationship prevents or makes difficult the establishment of a professional relationship; (3) administrative supervision - for example, clinical practice performed under administrative rather than clinical supervision by an institutional director or executive; (4) a primarily didactic process wherein techniques or procedures are taught in a classroom, workshop or seminar; (5) consultation, staff development, or orientation to a field or program, or role-playing of family interrelationships as a substitute for current clinical practice in an appropriate clinical situation.
Complete the following: Period of Supervision From: ____________________________ To:____________________________

(month, day, year) (month, day, year)
During the period of supervision listed above, the supervisee had __________hours of clinical practice (both individual and group) and I provided _________ hours of clinical supervision (must be minimum of one hour month). _______________________________________
(supervisors name) (type or print)
_______________________________________
(supervisors signature)
Date: ______________________ Address___________________________________________________ Email Address:_________________________________ Daytime Phone Number___________________
12
Submit a completed application to:
NC MFT Licensure Board PO Box 37669 Raleigh, NC 27627
CHECKLIST
Please review this checklist to ensure that all required documents are furnished to the Board. All items are mandatory. Failure to provide any of the requested information may result in the application being rejected as incomplete. APPLICATION: All sections are completed and the application has been signed and notarized. PHOTOGRAPH: Should measure approximately 2 x 2 and be taken within the past year. The
photograph is to be firmly affixed (not stapled) to the application, in the space provided.
FEE: Submit a $200 check or money order made payable to the NC MFT Licensure Board. The fee
is not refundable.
VERIFICATION OF EDUCATION: Official transcript(s) verifying your masters or doctors

degree with degree title and date of conferral posted. Must be in a sealed envelope mailed directly from the institution.
ETHICAL HISTORY: Documents or letters, if applicable, explaining prior convictions or

disciplinary action(s).
PROFESSIONAL ENDORSEMENTS: Endorsements (3). Must be in sealed envelopes with

endorsers signatures across the seals.
SUPERVISION AGREEMENT : Must be in a sealed envelope with supervisors signature

across the seal.
SUPERVISION REPORT(s) : Must be in a sealed envelope(s) with supervisors signature(s)

across the seal.
EXAMINATION VERIFICATION: Score transfer request form (if exam scores were not
reported/will not be reported to North Carolina) completed and mailed to examination reporting service.
COURSE CATALOG DESCRIPTIONS: Highlighted coursework descriptions from the

catalogue for the year in which the courses were taken.
AFFIDAVIT: Application signed and notarized. COPIES: Copies of all documents for your records with the exception of sealed documents. POSTAGE AND MAILING: Sufficient postage is on the mailing envelope. The application is submitted flat, not folded in an adequately sized envelope. PAGES FOR SUBMISSION: Pages 4 through 12 have been submitted. Pages 1, 2, 3,and 13 are
retained for my records.
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North Carolina Marriage and Family Therapy Licensure Board: Who Should Complete This Application

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North Carolina Marriage and Family Therapy Licensure Board: Who Should Complete This Application

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NORTH CAROLINA MARRIAGE AND FAMILY THERAPY LICENSURE BOARD

RESPONSIBILITY OF THE NC MFT LICENSURE BOARD

NC STATUTES AND RULES

Application - LMFT - Effective August 15, 2010