Excellence in Marriage and Family Therapy
2020 AAMFT CLINICAL FELLOW LICENSURE TRACK APPLICATION
American Association
for
Marriage and Family
T
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112
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Alfred
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Alexandria, VA
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Phone (703) 838-9808 Fax (703) 838-9805 E-mail
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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
central@aamft.org or 703-838-9808 to request a Clinical Fellow Evaluative Track Application.
For AAMFT Office Use Only
ID# ___________________
1. Member Information:
Salutation: _______
First Name: _________ M.I. ______
Last Name: _____________________________________
Former/Surname: ________________________________
Gender: ______________________________
Date of Birth*: ____________________________
Ethnicity*: _____________________________
Address:
Home Office
Organization: ____________________________________
Street Address:
___________________________________ Apt/Suite #:
_________________
City: __________________________________
State/Province: __________________________
Zip/Postal Code: ________________________
Country: __________________________
Phone: ________________________________
Email: _______________________________________
Additional address can be updated in your online profile
2. Member Credentials
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
preferred degree.
Degree: ______________________________(Required)
University or College from which your degree was obtained:
____________________________
(Required)
Licensure Information
Please check license held: LMFT LCMFT IMFT
State: ________________________________
License Number: _______________________
Expiration Date: ________________________
3. Would you like to be listed in our online
Membership Directory?
Yes
No
*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?
Yes No
Sig
nature:__________________________________ Date:___________________________
Your signature confirms that information you provided on this form are true, accurate and complete.
click to sign
signature
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2020 AAMFT CLINICAL FELLOW LICENSURE TRACK APPLICATION
2020 CLINICAL FELLOW CATEGORY OPTIONAL ENGAGEMENT PROGRAMS
AAMFT offers a number of optional engagement programs that members can join to enhance their member benefits. Geographic
programs focus on advocacy, networking, and education with a local flair. Topical Interest Networks focus on the growth of dedicated
areas of the profession. Membership in these programs provide access to networking, specialized education and training, and support
advocacy and practice advancement. Visit www.aamft.org/engage
for more information. Please select any engagement programs you
would like to join from the table below.
Opt-In? Engagement Program Annual Fee Opt-In? Engagement Program Annual Fee
Alabama Interest Network $50 Ohio Interest Network $50
Alberta Affiliate $73 Oklahoma Interest Network $60
Arizona Interest Network $70 Ontario Affiliate $50
Connecticut Interest Network $75 Oregon Interest Network $75
Florida Interest Network $25 Pennsylvania Interest Network $50
Georgia Affiliate $95 Rocky Mountain Family Therapy Network (CO, WY) $25
Idaho Interest Network $15 South Carolina Interest Network $85
Indiana Affiliate $85 Tennessee Affiliate $80
Kentucky Interest Network $50 Washington Interest Network $100
Louisiana Interest Network $80 Wisconsin Interest Network $86
Manitoba Affiliate $50 Couples and Intimate Relationships $25
MO/KAN Interest Network $30 Queer and Trans Advocacy Network $25
Montana Interest Network $10 MFT's Working in Trauma $25
New Hampshire Interest Network $60 Family Therapists in Schools $25
New Jersey Affiliate $135 Systemic Therapy Across the Lifespan $25
New York Interest Network $75 Working with Military Personnel and their Families $30
North Carolina Affiliate $95 Family Therapists in Healthcare $35
Margins to Center $20 Telehealth and Technology $20
Please select your application category.
New Applicant Transfer Applicant Reinstatement Applicant
Application Fee: __$25__ National Dues:__$216__ Engagement Programs Fee: _____
(Please refer to engagement programs chart if opting-in)
Total Dues & Fees Paid (USD Only): $________
(Please NOTE: Your payment must include the application-processing fee, national, and any engagement program fees, if applicable. Rates subject to change)
Payment Options:
I have enclosed a check or money order (must send via mail)
Please submit payable to AAMFT in U.S. currency ONLY. A service charge of $35.00 plus applicable charges from your bank institution is assessed for
returned checks.
I would like to pay by credit card:
VISA
Master Card
American Express
Discover
Name on Card: ______________________________ Credit Card #: _______________________________
Expiration Date: _______________ Security Code: ________
Signature: ________________________________ Date:_______________________
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