Fillable Marriage and Family Therapist Form 4 Applicant Experience (New York State Education Department)

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Marriage and Family Therapist Form 4 Applicant Experience (New York State Education Department)

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The University of the State of New York
The State Education Department
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Marriage and Family Therapist Form 4
Applicant Experience Record
Applicant Instructions
1. Complete both pages of this form. Be sure to sign and date item 9 before sending this form to the Office of the Professions at the address
at the end of the form.
2. For your experience to be considered, you must also complete Section I of Form 4B and forward the entire form and a copy of
Appendix A to each supervisor you list in Item 8 of this form.
1. Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2. Birth Date
Month Day Year
3. Print Name
Last
First
Middle
Licensee business address, phone and email address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
4. Mailing Address Home or Business
(You must notify the Department within 30 days of any address or name changes)
Line 1
Line 2
Line 3
City
State ZIP Code
Country/
Province
5. Telephone/Email Address
Daytime Phone
Home or Business
Area Code Phone
Email Address (please print clearly)
Home or Business
6. New York State DMV ID Number (Driver or Non-Driver ID)
(Leave this blank if you do not have a New York State DMV ID Number)
7.
Give any other names by which you have been known
Marriage and Family Therapist Form 4, Page 1 of 2, Revised 2/19
8.
List supervisor(s) who will verify your experience for licensure as a Marriage and Family Therapist. Attach additional sheets if necessary.
●
You must document 1,500 client clock hours of supervised Marriage and Family Therapy experience.
●
The supervisor(s) must meet the qualifications in Appendix A.
●
The supervisor(s) listed must have supervised your experience in the application of marriage and family therapy theories, techniques and supervisory
processes to assist applicant in developing skills necessary to practice Marriage and Family Therapy, which emphasizes the treatment or relational,
systemic dynamics in therapy and focuses on special training and techniques required for treating more than on person in therapy.
●
If a supervisor is deceased, you should list a licensed colleague who will attest to your supervised experience and to the qualifications of the deceased
supervisor.
Assigned
Number
Name of Supervisor and Address of Experience Setting
Dates of Experience
From To
Total Client
Contact Hours
1
2
3
4
5
6
9. Attestation
I declare and affirm that the statements made in the foregoing application, including accompanying statements are true, complete and
correct. I understand that any false or misleading information in, or in connection with my application may be cause for denial of licensure
and may result in criminal prosecution.
Applicant Signature Date
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Marriage
and Family Therapy Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Marriage and Family Therapist Form 4, Page 2 of 2, Revised 2/19
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Marriage and Family Therapist Form 4 Applicant Experience (New York State Education Department)

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Completed 22 June 2021

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