PROOF
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Marriage and Family Therapy Examiners
124 Halsey Street, 6th Floor, P.O. Box 45007
Newark, New Jersey 07101
(973) 504-6415
Documentation of Experience for
Marriage and Family Therapy Experience
Please print clearly.
Directions: This form is to be lled out by the applicant and veried by a qualied supervisor. A separate form must be used for each
setting and/or each time period in which supervised experience took place.
1. Name of applicant: _________________________________________________________________________________________
2. (Check the appropriate box)
Have you submitted these hours to the Board before?
Supervised experience after the date of Associate Licensure
If so, indicate the date of submission: ____________________
3. (Check the appropriate box)
Supervised experience prior to receiving a qualifying Supervised experience after receiving a qualifying
degree/certicate degree/certicate
4. The requirements for supervised experience in marriage and family therapy are as follows:
(1) A minimum of two of the three required years of counseling experience, which each consists of 1,500 hours and must occur after the
applicant has earned a qualifying degree and/or certicate as set forth in N.J.A.C. 13:34-2.3;
(a) for the required marriage and family counseling experience, client contact must total a maximum of 1,150 hours;
(b) for the required marriage and family counseling experience, face-to-face supervision must total a minimum of 50 hours,
of which no more than 25 hours may be group supervision; and
(c) a maximum of 300 hours in other work-related actvities (examples: recordkeeping, consultations, report writing, etc.).
5. Supervisors qualications:
(1) Name of supervisor (please print): ________________________________________________________________________________
(2)
License or Application Number: __________________________________________
(3) (Please check the category which is applicable.)
A New Jersey license to practice as a marriage and family therapist.
A New Jersey license to practice and is acting within the scope of the person’s profession or occupation and obtained from
an accredited institution a minimum of:
A masters degree in marriage and family therapy.
A masters degree in social work.
A graduate degree in a related eld and has demonstrated to the Board that he or she has completed course work
contentand training substantially equivalent to a masters degree in marriage and family therapy.
A graduate degree in a related eld which does not provide training and course work substantially equivalent in content
to a masters degree in marriage and family therapy, and is either a post graduate degree recognized by the Board, or a
program of training and course work at an institute or training program accredited by the Commission on Accreditation
for Marriage and Family Therapy Education.
Please enclose a curriculum vitae of the supervisor clearly documenting the degree held, the date the degree was conferred,
and at least ve years of full-time professional marriage and family therapy practice experience.
PROOF
6. Name and location of the setting in which applicant’s supervised experience took place:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
7. Type of setting: Non-Prot (bona de community agency)
For-Prot organization
8. Inclusive dates of supervision:
(a) From (month/day/year) _______________________ to (month/day/year) ____________________
9. Description of the applicant’s activities and responsibilities (use additional sheets of paper if necessary):
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
10. Number of hours in direct client contact: _________________
11. Number of hours in face-to-face supervision: ______________
12. Number of hours in group supervision: ___________________
13. Number of hours in other related activities: _______________
14.
Total number of hours (add numbers 9 through 12 above)
________
Signature of applicant: _____________________________________________________________ Date: ______________________
Signature of supervisor: ____________________________________________________________ Date: ______________________
* This form may be duplicated.
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