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APPLICATION FOR LICENSURE AS A MARRIAGE AND FAMILY THERAPIST (LMFT)
State Form 50710 (R / 2-06) Approved by State Board of Accounts, 2006

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 I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it. FOR OFFICE USE ONLY

APPLICATION FEE: DATE FEE PAID: RECEIPT NUMBER LICENSE NUMBER ISSUED: PERMIT NUMBER ISSUED: DATE LICENSE ISSUED:
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden or previous) Current address (number and street) City Permanent address (if different from above) Work telephone number Home telephone number E-mail address Place of birth (city and state) State ZIP code

Attach two passport quality photographs here (See instructions)

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Social Security number * Are you applying for a temporary permit?

Date of birth (month, day, year)

Yes

No

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 am currently licensed / certified in another state. Type of licensure / certification: Issued by (name of State Board): AND 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) Department Dates attended (mm/yy - mm/yy) Program title Degree earned

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GRADUATE EDUCATION (Masters or Doctoral) (continued)
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) Program title Degree earned Program title Degree earned

EMPLOYMENT HISTORY FOR THE PAST FIVE (5) YEARS Please list all places of professional employment, including self-employment.
Name of employer Location (city and state) Duties and responsibilities: Name of employer Location (city and state) Duties and responsibilities: Name of employer Location (city and state) Duties and responsibilities: Name of employer Location (city and state) Duties and responsibilities: Name of employer Location (city and state) Duties and responsibilities: Position or title Dates employed (mm/yy - mm/yy) Name of supervisor Average number of hours per week Position or title Dates employed (mm/yy - mm/yy) Name of supervisor Average number of hours per week Position or title Dates employed (mm/yy - mm/yy) Name of supervisor Average number of hours per week Position or title Dates employed (mm/yy - mm/yy) Name of supervisor Average number of hours per week Position or title Dates employed (mm/yy - mm/yy) Name of supervisor Average number of hours per week

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 No Type of License / Certificate / Registration / Permit 1. 2. 3. 4. 5. State Number Date Issued Status

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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? APPLICATION AFFIRMATION Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

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 I VERIFICATION OF SUPERVISION FOR LMFT LICENSURE APPLICANTS
State Form 50710 (R / 2-06)

APPLICANT: Complete the top section of this form, then forward it to your supervisor. You are authorized to photocopy this form as necessary.
Name (last, first, middle) Address (number and street, city, state, and ZIP code) Social Security number * Name of supervisor Supervisor title Date of birth (month, day, year) Telephone number (daytime) Maiden or given surname

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Name of business / institution Address (number and street, city, state, and ZIP code)

I hereby authorize
Signature of applicant

to furnish to the Professional Licensing Agency with the information below.
Date (month, day, year)

SUPERVISOR: Complete the remainder of this form. Return the completed form directly to the Professional Licensing Agency, 402 West Washington Street, Room W072, Indianapolis, IN 46204.
SUPERVISOR INFORMATION
Name of supervisor (last, first, middle) State license / certificate number / type of license / certificate Business address (number and street, city, state, and ZIP code) Number of years experience in Marriage and Family Therapy Marriage and Family Therapy supervision training Name of business / institution License / Certificate issued by Business telephone number

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E-mail address Supervisor of supervision Contact information of supervisor

APPLICANT EMPLOYMENT INFORMATION
Applicants job during the time of your supervision Date supervision began (month, day, year) Number of hours applicant worked per week Number of face to face client contact hours per week (A) Unmarried couples Number of hours applicant spent in direct service seeing: Brief description of how supervision was conducted: Applicants employer during the time of your supervision Date supervision ended (month, day, year) Number of hours you supervised applicant per week Number of clinical hours per week (B) Married couples Number of Family Therapy hours per week (C) Separating or divorced couples (D) Family groups, including children

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A. I was present at the applicants place of work. B. The applicants work requirement was at a different site but: (1) There was an equivalent supervisor on site. (2) The applicant was not engaged in independent private practice.

True

False

True True

False False

The above indicated supervision was performed by me pursuant to my order, control, and full professional and legal responsibility as a supervisor. I do hereby declare that the information contained herein is true and correct.
Signature of supervisor

Printed name of supervisor

SEAL OF NOTARY PUBLIC

Title

Date (month, day, year)

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FORM II VERIFICATION OF EMPLOYMENT/EXPERIENCE FOR LMFT LICENSURE APPLICANTS
State Form 50710 (R / 2-06)

APPLICANT: Complete the top section of this form, then forward it to your employer. You are authorized to photocopy this form as necessary.
Name (last, first, middle) Address (number and street, city, state, and ZIP code) Social Security number * Name business / institution Name of supervisor Date of birth (month, day, year) Address (number and street or rural route, city, state, and ZIP code) Supervisor title Telephone number (daytime) Maiden or given surname

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I hereby authorize
Signature of applicant

to furnish to the Professional Licensing Agency with the information below.
Date (month, day, year)

EMPLOYER: Complete the remainder of this form and have it notarized by a Notary Public. Return the completed form directly to the Professional Licensing Agency, 402 West Washington Street, Room W072, Indianapolis, IN 46204.
Name of employer Name of business / institution where employed Business address (number and street, city, state, and ZIP code) E-mail address

Telephone number of business / institution

APPLICANT EMPLOYMENT INFORMATION
Date employment began (month, day, year) Date employment ended (month, day, year) If currently employed, please indicate Number of hours applicant worked per week Number of clinical hours per week (B) Group (B) Married couples Number of Family Therapy hours per week (C) Marriage and Family Therapy (D) Family groups, including children

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Position held Number of face to face client hours per week Number of hours employee spent in direct service doing: (A) Individual

(A) Unmarried couples Number of hours employee spent in direct service seeing: Brief description of how supervision was conducted:

(C) Separating or divorced couples

The applicant pursuant to my order, control, and full professional and legal responsibility as an employer has performed the above-indicated experience. I do hereby declare that the information contained herein is true and correct.
Signature of employer

Printed name of employer

SEAL OF NOTARY PUBLIC

Title

Date (month, day, year)

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FORM III - A VERIFICATION OF MARRIAGE AND FAMILY THERAPY COURSEWORK
State Form 50710 (R / 2-06)

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 therapists 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
State Form 50710 (R / 2-06)

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
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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

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