Marriage and Family Therapy Application Forms

Instructions for completing and submitting the forms required for licensure appear below. You may also need to submit additional information (for example, examination scores). Please refer to the license requirements link on the left for complete information regarding all requirements you must meet.

Note: All forms are in Adobe Portable Document Format (PDF). To view or print these documents, you will need to have the free Adobe Reader External Link Icon installed on your computer. Download times and print quality will depend on your connection speed and printer.

Please type or print all information and sign all forms in black or blue ink. Original signatures are required on all forms.

Complete Application Packet
All forms and instructions in a single PDF file - Marriage and Family Therapist Application Packet ( PDF 155 KB)

Individual Application Forms

Form 1 - Application for Licensure - ( PDF 26 KB)

Important Notice: A New York State professional license is valid for life unless it is revoked, annulled, or suspended by the Board of Regents. To practice in New York State your professional license must be registered. If your registration has lapsed and you need to reregister, do not submit a Form 1. Instead, contact the Registration and Fees Unit to request a Delayed Registration Application by e-mailing: OPREGFEE@mail.nysed.gov, or by calling 518-474-3817 Ext. 410.  When e-mailing, be sure to include your profession, license number, address on record, new address (if changed), date of birth and the last 4 digits of your SSN.

All applicants for licensure must complete this form and submit it with the $371 licensure and first registration fee directly to the Office of the Professions at the address at the end of Form 1. Make checks payable to the New York State Education Department. NOTE: Your cancelled check is your receipt.

You must answer all questions and provide all information requested unless otherwise indicated. Failure to complete all required parts of the application will delay its review. Your signature on Form 1 must be notarized by a Notary Public.

Address/Name Change Form - Optional ( PDF 20 KB)
You are required to notify us within 30 days of any name or address changes. Please read the instructions and complete the appropriate sections of this form.
 
Form 2 - Certification of Professional Education - ( PDF 18 KB)
This form must be submitted directly by the educational institution(s) where you completed your creative arts therapy studies. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section before sending the entire form to your educational institution. Be sure to sign and date item 9 and include any fee required by the institution.
  • Section II: The Registrar must complete this section and return both pages of the form in an official school envelope directly to the Office of the Professions at the address at the end of the form. An official transcript is also required if the degree program was not registered by New York State as licensure qualifying or accredited by COAMFTE at the time you completed the program.

Form 3 - Verification of Other Professional Licensure/Certification - ( PDF 18 KB)
Complete this form if you hold, or have ever held, a license or certificate to practice any profession* in any jurisdiction.

This form must be submitted directly by the licensing/certifying authority. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section before sending the entire form to the licensing/certifying authority of each jurisdiction in which you are or have been licensed/certified. Be sure to sign and date item 8.
  • Section II: The licensing/certifying authority must complete this section, sign, date and return both pages of the form directly to the Office of the Professions at the address at the end of the form.

NOTE: A Form 3 is not required for licenses/certificates issued by the New York State Education Department.

*Profession is defined as professional titles licensed under New York State Education Law. (See page 2 of the Address/Name Change Form for a list of those titles.)

Appendix A - Requirements for Supervised Experience - (PDF PDF 11 KB)
Send this document to the licensed professional(s) who supervised your experience or will supervise your practice under a limited permit and/or the individuals endorsing your application for licensure along with the form you are asking them to complete.
 
Form 4 - Applicant Experience Record - ( PDF 17 KB)
Complete this form and send it to the Office of the Professions at the address at the end of the form. Be sure to sign and date item 8.
 
Form 4B - Certification of Supervised Experience - ( PDF 19 KB)
This form must be submitted directly by the licensed professional(s) who supervised your experience. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section before giving the entire form and a copy of Appendix A (PDFPDF 11 KB) to the licensed professional(s) who supervised your experience. Be sure to sign and date item 6.
  • Section II: The licensed professional(s) who supervised your experience must complete this section and return both pages of the form directly to the Office of the Professions at the address at the end of the form. The supervisor must be the supervisor named on your limited permit, for experience in New York.

A separate Form 4B must be submitted for each supervised experience you list on the Applicant Experience Record (Form 4).

Form 4E - Endorsement Applicant Experience Record - ( PDF 17 KB)
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.

Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to sign and date item 8.

You must also complete a separate Form 4F for each licensed colleague you list on the Endorsement Applicant Experience Record (Form 4E).

Form 4F - Certification of Licensed Experience - ( PDF 19 KB)
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.

This form must be submitted by the licensed colleague(s) who is attesting to your licensed practice as a Marriage and Family Therapist in another jurisdiction. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section and send the entire form to the licensed colleague who will attest to your experience as a Marriage and Family Therapist in another jurisdiction. Be sure to sign and date item 6.
  • Section II: The licensed colleague who will attest to your licensed experience must complete this section and return both pages of the form directly to the Office of the Professions at the address at the end of the form.

A separate Form 4F must be submitted for each licensed colleague listed on the Endorsement Applicant Experience Record (Form 4E).

Form 5 - Application for Limited Permit - ( PDF 19 KB)

  • Section I: Complete this section and give the form and a copy of Appendix A (PDF PDF 11 KB) to your prospective supervisor. Be sure to sign and date item 9.
  • Section II: Ask your prospective supervisor to complete this section.

Return the completed form with the $70 fee to the Office of the Professions at the mailing address at the end of the form.

Child Abuse Certification of Exemption Form - ( PDF 40 KB)
This form is not for all applicants. Use this form only if you are applying for an exemption to the requirement to complete training or coursework in the identification of child abuse and maltreatment because the nature of your practice excludes contact with persons under the age of 18 and persons 18 or older with a handicapping condition who reside in a residential care school or facility.
Last Updated: April 7, 2014
April 7, 2014