LARA/BPL-MARRIAGEFAMILYEDUC (Rev. 11/2018)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status,
disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this
agency.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 241-0199
www.michigan.gov/bpl
bpldata@michigan.gov
CERTIFICATION OF MARRIAGE AND FAMILY THERAPY EDUCATION
Authority: 1978 PA 368
This form must be submitted directly to this office by the Director of Education or the Registrar of the Institution in which you completed
your coursework or Marriage and Family Therapy degree. If this form is submitted by the applicant, it will not be accepted.
Print or Type
Middle Name
Student’s Social Security Number
Student’s Date of Birth (MM/DD/YYYY)
Name Educational Institution
Address of Educational Institution
Date of Admission
CERTIFICATION AND SIGNATURE
I certify the applicant named above (check one):
Attended the listed educational institution and was granted a Master’s Degree or Higher in Marriage and Family Therapy
from an MFT training program accredited by the Commission on Accreditation for Marriage and Family Therapy Training
Programs (COAMFTE) at a regionally accredited institution.
OR
Attended the listed educational institution and was granted a Master’s Degree from a regionally accredited institution and
has completed all of the following graduate-level courses:
• Three courses in family studies that total at least 6 semester or 9 quarter hours.
• Three courses in family therapy methodology that total at least 6 semester or 9 quarter hours.
• Three courses in human development, personality theory, or psychopathology that total at least 6 semester or 9
quarter hours.
• At least 2 semester or 3 quarter hours in ethics, law, and standards of professional practice.
• At least 2 semester or 3 quarter hours in research.
___________________________________________ ____________________________________
Signature of Program Director, or Registrar Date of Signature
___________________________________________
Type or Print Name of Dean, Director, or Registrar
SEAL – (If school has no seal, please indicate)
____________________________________________
click to sign
signature
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