Excellence in Marriage and Family Therapy
2020 AAMFT CLINICAL FELLOW LICENSURE TRACK APPLICATION
Marriage and Family
Phone (703) 838-9808 • Fax (703) 838-9805 • E-mail
Clinical Fellow membership is the credentialed level of membership in AAMFT. Clinical Fellows have met rigorous standards of
training in marriage and family therapy and are recognized worldwide for these standards. This application is designed for
individuals submitting proof of the highest level of licensing as a marriage and family therapist in states or provinces with licensing
laws approved by the AAMFT Board under criteria established by the AAMFT Board.
All United States Clinical Fellow applicants must apply using this application. All other applicants please contact AAMFT at
email@example.com or 703-838-9808 to request a Clinical Fellow Evaluative Track Application.
For AAMFT Office Use Only
1. Member Information:
First Name: _________ M.I. ______
Last Name: _____________________________________
Date of Birth*: ____________________________
___________________________________ Apt/Suite #:
Zip/Postal Code: ________________________
Additional address can be updated in your online profile
Please indicate the degree you would like to have listed in your AAMFT membership record.
This should be the degree that qualifies you to practice marriage and family therapy. The degree
you choose will appear in all correspondences and in AAMFT’s online Membership Directory.
Please be reminded of sections 9.4 and 9.5 of the AAMFT Code of Ethics when listing your
University or College from which your degree was obtained:
Please check license held: LMFT LCMFT IMFT
License Number: _______________________
Expiration Date: ________________________
3. Would you like to be listed in our online
*All optional items are kept confidential and used only for accuracy in
identifying record & membership diversity, creating future programs
and customizing member offers and communications.
4. Statement of Professional Ethics and Conduct (This question MUST be answered. If you answer “yes” to this question,
please provide detailed information on a separate piece of paper.)
Have you ever been convicted of a felony or of any misdemeanor which might relate to your qualifications or functions as a
therapist or other professional; or have you ever had your registration, certification or license to practice in the health care
industry suspended, revoked, restricted or denied; or has any other disciplinary action been taken against you by any federal,
state, or provincial regulatory body or foreign jurisdiction; or are you presently under investigation by any regulatory body to the
best of your knowledge?
Your signature confirms that information you provided on this form are true, accurate and complete.
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