PROOF
New Jersey Ofce 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 veried by a qualied 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/certicate degree/certicate
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 certicate 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. Supervisor’s qualications:
(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 master’s degree in marriage and family therapy.
A master’s 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 master’s 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 master’s 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.
