Marriage And Family Therapy Form 4b - Certification Of Supervised Experience

Section II: Certification of Supervised Experience

Instructions to Supervisor: Complete Section II, Items A and B, sign and date the affidavit and send both pages of this form directly to the address at the end of this form. Your

signature on this form must be notarized by a Notary Public. This form will not be accepted if returned by the applicant. If the supervised experience occurred outside

of New York State, you must include a copy of your license and an operating certificate or authorization for the entity to provide professional services.

A. Supervisor's Qualifications: I have reviewed Appendix A and I meet the qualifications as a supervisor.

I am a licensed _______________________________________________________________ in ______________________________

Professional Title

State

____________________________________________________________________________

_____________________________________________________________

License number (Attach a copy of your license if other than New York)

Date licensed

B. Experience Information: I am attesting that I supervised ___________________________________________________________ for

Applicant Name

at least one hour per week or two hours every other week in the practice of Marriage and Family Therapy (defined below) as

follows.

_____________________________________________________________________________________________________________

Address of setting where experience took place

City

State

Zip Code

Present

Dates of Experience:

From _______ / _______ / _______ To _______ / _______ / _______

mo.

day

yr.

mo.

day

yr.

Total client contact hours practicing Marriage and Family Therapy: ________________________

“The practice of Marriage and family therapy is defined as 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.”

Affidavit with Acknowledgement (Notarization required.)

Supervisor

I declare and affirm that the statements made in the foregoing application, including any attached statements, are true, complete and

correct and that the experience I am attesting to meets the requirements for supervised experience detailed in Appendix A. This form

must be signed and dated in the presence of a Notary Public.

Check here if you are attaching additional information.

Signature: ______________________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

Print Name: _____________________________________________________________________

Address:________________________________________________________________________

________________________________________________________________________

Phone: _________________________________ Fax: ___________________________________

E-mail: _________________________________________________________________________

Notary

State of __________________________________________________ County of __________________________________________

On the ____________ day of ______________________ in the year __________ before me, the above signed, personally appeared

__________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual

whose name is subscribed to this application and acknowledged to me that he/she executed the application and swore that the

statements made by him/her in the application and all supporting materials are true, complete, and correct.

Notary Public signature _________________________________________________________________________________________

Notary ID number _______________________________

Notary Stamp

Expiration date __________ / __________ / __________

Month

Day

Year

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 4B, Page 2 of 2, Rev. 11/15

Marriage And Family Therapy Form 4b - Certification Of Supervised Experience - 2015 Page 2

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