north carolina marriage and family therapy licensure board

Application packet request form

to receive an application packet – send this form to

  • Complete all information requested in the form below. Type or print legibly.
  • Incomplete or forms missing information are subject to a processing delay.
  • Completion of the following will ensure you receive all forms and information to navigate the licensure process.

Legal Name: ______

(first, middle, last)

Previous Name(s): ______

(list all names, in reverse chronological order)

Current Mailing Address: ______

(street or box, city, state, zip)

Day Time Phone # ______

(include area code)

Email Address: ______

(list one email address only; to be used for contact to and from the Board)

ANSWER ALL QUESTIONS BELOW:

  1. Do you have a minimum of a master’s degree from a recognized educational institution regionally accredited Regional Accreditors in the field of marriage and family therapy, or a related degree per NC Statute 90-270.47 NC Statutes? ☐ Yes ☐ No
  1. If your degree has not been conferred (as evidenced by an official transcript), when is your degree scheduled to be conferred? (List month, date, year)
  1. Have you passed the National MFT Examination (Exam recognized by NC for MFT licensing)? ☐ Yes ☐ No
  1. Are you currently licensed as a marriage and family therapist in another state? ☐ Yes ☐ No

If yes, list the following: Licensed State(s)License Number(s)

  1. Are you Active Duty Military or the Spouse of an Active Duty Member of the Military? ☐ Yes ☐ No
  1. Do you have at least 1500 hours of documented clinical experience (face-to-face therapy) in the practice of marriage and family therapy, not more than 500 hours of which were obtained while a student in your qualifying degree program, with at least 1000 of which were obtained after the degree was granted. A minimum of 200 supervision hours in conjunction with the reported clinical experience must have been with an AAMFT Approved Supervisor or Approved Supervisor Candidate (recognized supervisory credential)? ☐ Yes ☐ No

Check One:☐ Send application forms via mail (allow 7-10 business days)

☐ Send application forms via email attachment (allow up to 3 business days for a response)

There is no fee for requesting an application packet.

Fees for submitting applications and taking the National MFT Examinationare required.

Form Date: 1/9/18Questions: