Continuing Education Documentation Form - Board Of Marital And Family Therapy

BOARD OF MARITAL AND FAMILY THERAPY

CONTINUING EDUCATION DOCUMENTATION

This form must accompany your renewal form. If the form is not attached, it may cause a delay in the processing of your license. Therefore, please be sure that it is attached to

your renewal.

Name:

License No.:

(Please print or type)

NOTE: For those licensees holding license numbers 0001 to 0216, you must document 45 contact hours which include two contact hours of professional ethics. Those with license numbers

0217 to 0218 must document 30 contact hours which includes two contact hours in professional ethics. Licensees with numbers 0219 and above must document 23 contact hours which includes

two contact hours in professional ethics.

DATES OF

NAME OF

SPONSORING

ADDRESS/LOCATION

HOURS

ATTENDANCE

COURSE TITLE

INSTRUCTOR

ORGANIZATION

(if applicable)

CLAIMED

PROFESSIONAL ETHICS

TOTAL

APPROVED SUPERVISOR CONTINUING EDUCATION (12 AAC 19.210(b)) Completed at least 6 contact hours of CE related to the practice of supervising a marital and family therapist.

A supervisor may also include those 6 hours in the total hours required for license renewal.

TOTAL HOURS OF CONTINUING EDUCATION must be at least 45 hours for License Number 1-216, 30 contact hours for License Number 217-218, and 23 contact hours for License Numbers

219 and above. If needed, you may make additional copies of this form.

Applicant Signature

08-4115a (Rev. 10/00)

(3)