Marriage And Family Therapy Form 4f - Certification Of Licensed Experience - 2015
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1
2The University of the State of New York
Marriage and Family
Assigned No.
THE STATE EDUCATION DEPARTMENT
(From Form 4E)
Office of the Professions
Therapist Form 4F
Division of Professional Licensing Services
__________
Certification of Licensed Experience
This form is for applicants seeking licensure in New York State by endorsement of a license to practice Marriage and Family
Therapy issued by another jurisdiction. You must have at least 5 years of licensed experience in Marriage and Family Therapy in
the 10 year period prior to applying for licensure in New York State.
Applicant Instructions
1.
Complete Section I. In item 3, enter your name as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 6.
2.
Send this entire form to a licensed colleague to complete Section II. The licensed colleague must return both pages of the form directly
to the Office of the Professions at the address at the end of the form. The form must bear an original notarized signature of the licensed
colleague and date. If additional copies are needed, you may photocopy this form. This form will not be accepted if returned by the
applicant.
Section I: Applicant Information
1
2
1.
Social Security Number
2.
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
3.
Print Name As It Appears On Your Application for Licensure (Form 1)
Last
First
Middle
4
.
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
Name at time of employment (if different from above): _________________________________________________________________
5
6.
Name of licensed colleague: ____________________________________________________ Assigned number from Form 4E _______
I practiced Marriage and Family Therapy as defined below:
Marriage and family therapy is the assessment and treatment of nervous and mental disorders, whether affective, cognitive or behavioral, which results in dysfunctional
interpersonal family relationships including, but not limited to familial relationships, marital/couple relationships, parent-child relationships, pre-marital and other personal
relationships; and the use of mental health counseling, psychotherapy and therapeutic techniques to evaluate and treat marital, relational, and family systems, and individuals
in relationship to these systems; and the use of mental health counseling and psychotherapeutic techniques to treat mental, emotional and behavioral disorders and ailments
within the context of marital, relational and family systems to prevent and ameliorate dysfunction; and the use of assessment instruments and mental health counseling and
psychotherapy to identify and evaluate dysfunctions and disorders for purposes of providing appropriate marriage and family therapy services.
Jurisdiction where I practiced Marriage and Family Therapy: ___________________________________________________________
Date of licensure: _______ / ______ / _______ License number ____________________
mo.
day
yr.
.
I request and give my permission to the individual listed in item 5 above to complete Section II of this form and mail it to the New York
6
State Education Department at the address at the end of this form, and to release any other information requested by the State
Education Department in connection with my application for licensure. I also declare and affirm that the statements made in this
application, including accompanying documents, 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 or loss of licensure and may result in criminal prosecution.
_____________________________________________________________________________ Date ________ / _______ / ________
Signature of applicant
mo.
day
yr.
Marriage and Family Therapist Form 4F, Page 1 of 2, Rev. 11/15
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