Free 53737.FH11 - Indiana

APPLICATION FOR LICENSURE AS A MARRIAGE AND FAMILY THERAPIST ASSOCIATE (LMFTA)
State Form 53737 (10-08) Approved by State Board of Accounts, 2008

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SOCIAL WORKER MARRIAGE AND FAMILY THERAPIST AND MENTAL HEALTH COUNSELOR BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2064 E-mail: [email protected]

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

FOR OFFICE USE ONLY APPLICATION FEE: DATE FEE PAID (month, day, year): RECEIPT NUMBER LICENSE NUMBER ISSUED: PERMIT NUMBER ISSUED: DATE LICENSE ISSUED:

Attach one passport quality photographs here (See instructions)

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden or previous) Current address (number and street, city, state, and ZIP code) Permanent address (if different from above) Work telephone number Home telephone number E-mail address Place of birth (city and state)

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Social Security number *

Date of birth (month, day, year)

Please indicate exactly how you wish your name to appear on your license.

Please check all that apply: I am applying for licensure by examination. I am applying for licensure by exemption from examination (ENDORSEMENT) I successfully passed the AAMFTRB examination. Date: State taken in: OR I have passed the (name of examination) Date: State taken in: GRADUATE EDUCATION (Masters or Doctoral)
Name of academic institution Location (city and state) Name of academic institution Location (city and state) Name of academic institution Location (city and state) Department Dates attended (mm/yy - mm/yy) Department Dates attended (mm/yy - mm/yy) Department Dates attended (mm/yy - mm/yy) Program title Degree earned Program title Degree earned Program title Degree earned

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OTHER STATE LICENSURE / CERTIFICATION Do you hold, or have you ever held, a license / certification / registration / permit to practice any regulated health profession by a state licensing board? (If yes, list all states below, including Indiana, in which you have held a license / certification / registration / permit to practice any state regulated occupation.) Yes Type of License / Certificate / Registration / Permit 1. 2. 3. 4. 5. State Number Date Issued Status No

ALL APPLICANTS MUST ANSWER THE FOLLOWING QUESTIONS If your answer is yes to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location and date and disposition. If malpractice, provide name(s) of plaintiff(s). Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 2. Have you ever been denied license, certificate, registration or permit to practice medicine, osteopathic medicine or any regulated health occupation in any state (including Indiana) or country? 3. Are you now being, or have you ever been treated for drug or alcohol abuse? 4. Have you ever been convicted of, plead guilty to or nolo contendre to: (A) a violation of a Federal, State, or local law relating to the use, manufacturing, distribution or dispensing of controlled substance or drug addiction? (B) any offense, misdemeanor or felony in any state? (except for minor violations of traffic laws resulting in fines) 5. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline of limitations? 6. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign or retire from any hospital or health care facility in which you have trained, held staff membership or privileges or acted as a consultant? 7. Have you ever had a malpractice judgment against you or settled any malpractice action? Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

APPLICATION AFFIRMATION I hereby swear or affirm under the penalties perjury that the above statements are true, complete and correct.
Signature of applicant Date (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency, or the Indiana Social Worker, Marriage and Family Therapist and Mental Health Counselor Board, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Board, or any of their authorized representatives in connection with processing my application for licensure. I hereby release the aforementioned persons, firms, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency, or the Indiana Social Worker, Marriage and Family Therapist and Mental Health Counselor Board, to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information which is material to my application, and I hereby specifically release the Agency, and the Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to same.
Signature of applicant Date signed (month, day, year)

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FORM III - A VERIFICATION OF MARRIAGE AND FAMILY THERAPIST ASSOCIATE COURSEWORK
Part of State Form 53737 (10-08)

All information on this form must be typed or clearly printed. This is a two page form. Please list the course titles in the areas indicated below, or the graduate courses, as they appear on your transcript, that in your opinion, meet the following requirements. If the title of the course you are wishing to apply towards these requirements does not clearly reflect these content areas, you should also submit additional supporting documentation, such as course descriptions from your college or universitys catalog. Twenty-seven (27) semester hours or forty-one (41) quarter hours of graduate coursework that must include graduate course credits with material in at least the following content areas. Please indicate whether these are semester or quarter hours below.
Theoretical Foundations of Marriage and Family Therapy
Name of educational institution Course number Course title Credit hours Semester Quarter

Major Models of Marriage and Family Therapy
Name of educational institution Course number Course title Credit hours Semester Quarter

Individual Development
Name of educational institution Course number Course title Credit hours Semester Quarter

Family Development and Family Relationships
Name of educational institution Course number Course title Credit hours Semester Quarter

Clinical Problems
Name of educational institution Course number Course title Credit hours Semester Quarter

Collaboration with Other Disciplines
Name of educational institution Course number Course title Credit hours Semester Quarter

Sexuality
Name of educational institution Course number Course title Credit hours Semester Quarter

Gender and Sexual Orientation
Name of educational institution Course number Course title Credit hours Semester Quarter

Issues of Ethnicity, Race, Socioeconomic Status, and Culture
Name of educational institution Course number Course title Credit hours Semester Quarter

Therapy Techniques
Name of educational institution Course number Course title Credit hours Semester Quarter

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Behavioral Research That Focuses on the Interpretation and Application of Research Data as it Applies To Clinical Practice
Name of educational institution Course number Course title Credit hours Semester Quarter

The previously mentioned content areas may be combined into any one (1) graduate level course, if the applicant can prove that the coursework was devoted to each content area. One graduate level course of two (2) semester hours or three (3) quarter-hours in the following areas. Please indicate whether these are semester or quarter hours below. Legal, Ethical, and Professional Standards Issues in the Practice of Marriage and Family Therapy
Name of educational institution Course number Course title Credit hours Semester Quarter

Appraisal and Assessment for Individual or Interpersonal Disorder or Dysfunction
Name of educational institution Course number Course title Credit hours Semester Quarter

I, the undersigned applicant for marriage and family therapist associates licensure, do hereby certify that I have also completed the following: A specified clinical practicum, internship or field experience in marriage and family therapy of at least five hundred (500) hours of face-to-face client hours with individuals, couples and families for the purpose of assessment and intervention, that was conducted over a period of one (1) year at an average rate of ten (10) hours of clinical contact per week. Of the five hundred (500) hours, no more than fifty percent (50%) of this time was spent with individuals. This practicum also included a minimum of one hundred (100) hours of supervision administered by a licensed marriage and family therapist who has at least five (5) years of experience as a qualified supervisor. The following graduate work may NOT be used to satisfy the content area requirements above: (1) Thesis or Dissertation Work (2) Practicum, Internships, or Field Work
Signature of applicant Date (month, day, year)

Printed name of applicant

Social Security number *

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FORM III - B GRADUATE COURSEWORK CONTENT AREAS
Part of State Form 53737 (10-08)

THEORETICAL FOUNDATIONS OF MARRIAGE AND FAMILY THERAPY Studies that provide an understanding of the epistemology of family therapy. A. Theories of individual and family development and transitions across the life-span; B. Theories of family therapy; MAJOR MODELS OF FAMILY THERAPY Studies that provide an understanding of clinical practices and treatments of Family Therapy. A. Structural and Strategic Family Therapy B. Brief Family Therapy C. Solution Oriented Family Therapy D. Narrative Family Therapy INDIVIDUAL DEVELOPMENT Studies that provide an understanding of a persons development. A. Life-span human development B. Child psychology and development C. Adolescent developmental stages D. Adult in mid-life or menopausal women, etc. FAMILY DEVELOPMENT AND FAMILY RELATIONSHIPS Studies that provide an understanding of family development and varying relationships within the family. A. Advanced family studies, B. Family stages during the life cycle CLINICAL PROBLEMS Studies that provide an understanding of problems affecting a family system A. Treating the abusing family B. Family treatment of incest C. Clinical treatment of alcoholism and other addictions in the family D. Helping a family cope with crisis COLLABORATION WITH OTHER DISCIPLINES Studies that provide an understanding of family therapy approaches cooperating with other professionals. A. Behavior disorders B. Medical management and family therapy in ADD and ADHD C. Psychological Testing and how it relates to borderline families D. Family therapy in a school setting SEXUALITY Studies that provide an understanding of sexuality in the family. A. Human sexuality B. Treating sexual dysfunction C. Principles, practices, and applications of sexual abuse treatment GENDER AND SEXUAL ORIENTATION Studies that provide an understanding of the range of sexual differences. A. Human sexuality B. Gender and transgender clinical problems C. Comparing and contrasting treatment regarding issues of heterosexuality, bisexuality and homosexuality D. Homosexual and bisexual couples and families ISSUES OF ETHNICITY, RACE, SOCIOECONOMIC STATUS AND CULTURE Studies in this area include, but are not limited to, the following: A. Special clinical problems pertaining to treatment of African American, Asian and Hispanic families B. Clinical problems of the working poor C. First generation immigrant families THERAPY TECHNIQUES Studies in this area include, but are not limited to, the following: A. Family therapy skills B. Family sculpting C. The use of genograms in family therapy BEHAVIORAL RESEARCH THAT FOCUSES ON THE INTERPRETATION AND APPLICATION OF RESEARCH DATA Studies in this area include, but are not limited to, the following: A. Research methods in child and family studies B. Qualitative research in marriage and family studies LEGAL, ETHICAL, AND PROFESSIONAL STANDARDS AND ISSUES IN THE PRACTICE OF MARRIAGE AND FAMILY THERAPY A. Professional issues in marriage and family therapy B. Ethical issues in marriage and family therapy APPRAISAL AND ASSESSMENT FOR INDIVIDUAL OR INTERPERSONAL DISORDER OR DYSFUNCTION A. The use of the DSM in diagnosis B. Comparing and contrasting the GAF and the GARF Page 5 of 6

FORM P - 1 VERIFICATION OF PRACTICUM FOR LICENSURE AS A MARRIAGE AND FAMILY THERAPIST ASSOCIATE (LMFTA)
Part of State Form 53737 (10-08)

INSTRUCTIONS:

1. 2.

The applicant must complete Section A, then forward to the educational institution at which the practicum was completed. Section B must be completed by an official of the institution that has granted the academic credit for this supervised clinical experience. SECTION A - APPLICANT INFORMATION

Name of applicant (last, first, middle, maiden or previous)

Social Security number *

My minimum five hundred (500) hour practicum was completed under the auspices of the following educational institution:
Name of institution Location (city and state) Date practicum began (month, year) Date practicum was completed (month, year)

I completed the practicum at the following location:
Specific location of field experience

SECTION B - VERIFICATION OF COMPLETION OF FIVE HUNDRED (500) HOUR PRACTICUM As an official of the school named above, I certify that the above-named applicant has completed at least the following experience during the completion of the practicum: 1. The applicant has completed at least five hundred (500) face-to-face client hours with individuals, couples, and families for the purpose of enabling the student to develop basic therapy skills and to integrate professional knowledge and skills. 2. The applicant has conducted the required five hundred (500) hours over a period of one (1) year, at an average rate of ten (10) hours of clinical contact per week and no more than fifty percent (50%) of this time was spent with individuals. As an official of the school named above, I certify that the above-named applicant did receive the following supervision during the completion of the practicum. For the purposes of this certification, individual supervision is supervision rendered to not more than two (2) individuals at a time and group supervision is supervision rendered to at least two (2) and not more than ten (10) individuals at a time. During the completion of this practicum, the applicant did receive the following number of hours of supervision: __________________ I further certify that the supervision for this practicum was conducted by either a program faculty member or a supervisor working under the supervision of a program faculty member using audiotape, videotape, and/or direct observation. The applicants supervisor(s) held the following position(s), degree(s), license(s), and/or certification(s). (Provide name(s) and qualifications below.)
Signature of school official Printed name of school official Name of program faculty member Name of site supervisor Name of institution Name of applicant (last, first, middle, maiden or previous) Title of school official Name of alternate supervisor Position held at the institution Date (month, day, year)

Return this completed form to: PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204

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