List supervisor(s) who will verify your experience for licensure as a Marriage and Family Therapist. Attach additional sheets if necessary.
You must document 1,500 client clock hours of supervised Marriage and Family Therapy experience.
The supervisor(s) must meet the qualifications in Appendix A.
The supervisor(s) listed must have supervised your experience in the application of marriage and family therapy theories, techniques and supervisory
processes to assist applicant in developing skills necessary to practice Marriage and Family Therapy, which emphasizes the treatment or relational,
systemic dynamics in therapy and focuses on special training and techniques required for treating more than on person in therapy.
If a supervisor is deceased, you should list a licensed colleague who will attest to your supervised experience and to the qualifications of the deceased
Name of Supervisor and Address of Experience Setting
Dates of Experience
I declare and affirm that the statements made in the foregoing application, including accompanying statements are true, complete and
correct. I understand that any false or misleading information in, or in connection with my application may be cause for denial of licensure
and may result in criminal prosecution.
Applicant Signature Date
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Marriage
and Family Therapy Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Marriage and Family Therapist Form 4, Page 2 of 2, Revised 2/19