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South Carolina

Application and Education Review

for Licensure as a Marriage and Family Therapist

or Marriage and Family Therapy Associate

2020 Application

This application form is interactive.

Download the form to your computer to ll it out.

3 TERRACE WAY

GREENSBORO, NORTH CAROLINA 27403-3660 USA

TEL: 336-482-2856 * FAX: 336-482-2852

www.cce-global.org * cce@cce-global.org

The Center for Credentialing & Education, Inc. (CCE



) values diversity.

There are no barriers to certication on the basis of gender, race, creed, age, sexual orientation or national origin.

CCE and NBCC are registered trade and service marks of the National Board for Certied Counselors, Inc.





, Addiction Counselors,

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associate









 

 Code of Ethics

 

 

https://llr.sc.gov/.

Code of Regulationsassociate





HOW TO CONTACT CCE

 

 

 

 



Reviews are conducted in order of receipt and completed within six weeks. Applicants are notified of review

results via postal mail.

Delays result from incomplete applications. 









This application supersedes any previous versions.

South Carolina LMFT Review

LMFT Intern

General:

A



Examination: 















Application Completion Process: 







CCE Review Appeals Process: 





Code of Laws and Code of Regulations











Ofcial Licensure Approval: 



South Carolina licensing boardA







 foursix



 



 



 2



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South Carolina LMFT Review

LMFT Associate

Practice As An LMFT Associate: Licensure as an LMFT/Aallows an individual to begin practicing under the

supervision 





2







A







Note: Associate



0





AAssociate



Associate

Associate



Associate

Associate





(1) 





(2) 





Supervision Requirements: 







Associate2



 

2

associate





 

 associate

 

 8

 

associate 



1. Licensure and Education Review Application (pages 12-20)

The Affidavit of Eligibility (pages 15-16) must be completed, signed, and notarized. A copy of your driver's

license or other identification (as specified by applicant on page 15) AND a copy of your social security card

must be provided for identification purposes.   

 

2. LMFT Application fee of $170





63223Charlotte

28263-3223











3. Official Transcript











CCE









4. Coursework Descriptions











5. Plan for Clinical Supervision of Post-Master’s Client Contact in Marriage and Family Therapy

(pages 21-23)



associate

6. Examination Scores (if applicable)





South Carolina LMFT Review

LMFT Associate Checklist













.

Supervised Experience:















South Carolina LMFT Review

LMFT Licensure by Endorsement



1. Application and Education Review Form (pages 12-20)

, signed and notarized A copy of your driver’s

license or other identification (as specified on page 15) AND a copy of your social security card must be

provided for identification purposes.  



2. LMFT Application fee of $170





paymentCCE, P.O. Box 63223, Charlotte, NC 28263-3223transcripts 

 





3. Official Transcript(s) and Copies of Coursework Descriptions for the Course Requirements and

Practicum/Internship







4. Coursework Descriptions







5. Verification of Licensure (page 26)



6. Official Examination Score Verification





7. Confirmation of Clinical Supervision





8. Log for Clinical Supervision of Post-Master’s Clinical Experience



9. Copy of Your License

 

South Carolina LMFT Review

LMFT Licensure by

Endorsement Checklist

Graduate Degree:a minimum of 48 graduate

semester hours (or 72 quarter hours) in marriage and family therapy







an earned master’s degree, specialist degree or doctoral degree.



Required Graduate-Level Coursework:







Please see pages 9-10 for detailed coursework requirement descriptions.

1. Theoretical Foundations 

an introductory course 

2. Clinical Practice

Must include one course in psychopathology or diagnostics of psychopathology 



3. Individual Development and Family Relations

4. Professional Identity, Legal and Ethical Issues

5. Research

6. Clinical Experience/Practicum

5

10

 



Coursework/Degrees Completed Outside The United States: 

















































South Carolina LMFT Review

Educational Requirements for an

LMFT or Associate

DETAILED REQUIREMENTS FOR COURSEWORK AND CLINICAL EXPERIENCE

for Licensure as a Marriage and Family Therapist or Marriage and Family Therapy Intern

Denition of Categories for Required Coursework

1. Theoretical Foundations











 

 

 

 

 

 

 

 

 

2. Clinical Practice











One

or



a. 

b. 

c. 

d. 

e. 

f. 

g. 



Description of Psychopathology





a. 

 

c. 

d. 

e. 

f. 

g. 



h. 



i. Diagnostic and Statistical Manual of Mental Disorders (DSM), other



 

Description of Diagnostics of Psychopathology

DSM



a. DSM 

 



c. DSM

d. 

e. 

f. DSM

3. Individual Development and Family Relations











4. Professional Identity, Legal and Ethical Issues



 

 

 

a. 

b. 

c. 

d. 

e. 

5. Research









a. 

b. 

c. 

6. Clinical Experience



5



10



Please note:



















Note: 



FEES

(paid to CCE) 

(paid to PTC)

Associate(paid to the South Carolina Board)





Applications will be held open for three years.



associate 

HOW TO CONTACT CCE

Telephone: 

E-mail:

Fax: 

 

63223

Charlotte 28263-3223

 





ou should receive a response to your reviewed application within four to six weeks. Applications and any

supplemental material are reviewed in the order in which they are received. In order to protect applicants from

miscommunication or misinformation, we require those with questions regarding their application to communicate

in writing via e-mail, postal mail and fax. We review applications and respond to questions in the order in which

they are received.

South Carolina LMFT Review

Examination Dates and Fees





,

Addiction Counselors,





CCE

63223

Charlotte28263-3223

Associate



INSTRUCTIONS

 

              



This application will remain open

for three years from the initial date submitted to CCE.

2. 

 

CHECK ONE.

1. Title:

   Mr.    







2. Home Address







 





South Carolina LMFT Review

Application and Education Review Form

4. Gender:  Male  

 



5. Have you taken and passed the National Marital and Family Therapy Examination?   

: 

Attach copy of exam score report (if available). Score verication must be submitted to CCE directly from PTC.

Contact PTC at 212-356-0660 for scores.

6. Education: 







Education College/University

Degree Date Conferred Major

Credits Earned

Master’s Degree

Post-Master’s

Coursework

Doctoral Degree

3. Employer Name









7. If you have been or are currently licensed (in any profession) in any other state(s), please document below:

State

License

Number

Date

Licensed

Expiration

Date

Lapsed

Revoked/

Suspended

Probation

Profession/

Field

    

   Multiracial  

8. Personal History Information:

attached letter.

 

 

 



 

 



 

 



  

 





 

 



  

 





 

If yes, attach a certied copy of the court records regarding your

conviction, the nature of the offense, and date of discharge (if applicable).

Also, you must have a statement from the probation or parole ofcer sent

directly to the board from the above-mentioned authorities.

 





 

 

  

 



  

 



  

Rev: 02-02-2015

STATE OF SOUTH CAROLINA

DEPARTMENT OF LABOR, LICENSING AND REGULATION

VERIFICATION OF LAWFUL PRESENCE IN THE UNITED STATES

AFFIDAVIT OF ELIGIBILITY

Pursuant to Section 8-29-10, et seq. of the South Carolina Code of Laws (1976, as amended), the Department

of Labor, Licensing and Regulation must verify that any person who applies for a South Carolina license is

lawfully present in the United States. Complete and sign this affidavit of eligibility. The information provided is

subject to verification.

Section A: LAWFUL PRESENCE in the United States.

The undersigned _ _____, of

(Print clearly First, Middle, and Last name) (Home Address, City, State, and Zip Code)

being first duly sworn deposes and states as follows:

Section B: ATTESTATION.

I understand that in accordance with section 8-29-10 of the South Carolina Code of Laws, a person who

knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall, in

addition to other sanctions imposed by this State or the United States, be guilty of a felony, and upon

conviction must be fined and/or imprisoned for not more than 5 years (or both).

I understand that the representations made in this Affidavit shall apply through any license(s) or renewals

issued, and that I shall have an affirmative duty to immediately advise the Department of Labor, Licensing and

Regulation of any change of my immigration or citizenship status.

I swear and attest the information contained herein is true and correct to the best of my knowledge. I

understand that under South Carolina law, providing false information is grounds for denial,

suspension, or revocation of a license, certificate, registration or permit.

Signature of Affiant

SWORN to before me this day of , 20

Notary Signature

Print Name

Notary Public for

My Commission Expires:

Check only one box:

1. I am a United States citizen; or

I am a Legal Permanent Resident of the United States eighteen years of age or older; or

I am a Qualified Alien or non-immigrant under the Federal Immigration and Nationality Act, Public Law

82-414, eighteen years of age or older, and lawfully present in the United States.

Other:

Please submit any documentation that supports this status.

Date of Birth: _

Alien Number: _

I-94 Number:

(If you checked number 2, 3, or 4 you must attach a copy of your immigration documents. See

instruction sheet for a list of accepted immigration documents.)

Rev: 02-02-2015

INSTRUCTION SHEET FOR COMPLETING AFFIDAVIT OF ELIGIBILITY

CHECK box 1:

If you are a United States Citizen by birth or naturalization

CHECK box 2:

If you are a Legal Permanent Resident and you are not a U.S. Citizen, but are residing in the U.S. under legally

recognized and lawfully recorded permanent residence as an immigrant.

PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS.

CHECK box 3:

If you are a Qualified Alien. You are a Qualified Alien if you are:

An alien who is lawfully admitted for residence under the INA.

An alien who is granted asylum under Section 208 of the INA.

A refugee who is admitted to the United States under Section 207 of the INA.

An alien who is paroled into the United States under Section 212(d)(5) of the INA for a period of at least 1 year.

An alien whose deportation is being withheld under Section 243(h) of the INA (as in effect prior to April 1, 1997)

or whose removal has been withheld under Section 241(b)(3).

An alien who is granted conditional entry pursuant to Section 203(a)(7) of the INA as in effect prior to April 1,

1980.

An alien who is a Cuban/Haitian Entrant as defined by Section 501(e) of the Refugee Education Assistance Act

of 1980.

An alien who has been battered or subjected to extreme cruelty, or whose child or parent has been battered or

subject to extreme cruelty.

PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS.

ACCEPTED IMMIGRATION DOCUMENTS:

Unexpired Reentry Permit (I-327)

Permanent Resident Card or Alien Registration Receipt Card With Photograph (I-551)

Unexpired Refugee Travel Document (I-571)

Unexpired Employment Authorization Card Which Contains a Photograph (I-766)

Machine Readable Immigrant Visa (with Temporary I-551 Language)

Temporary I-551 Stamp (on passport or I-94)

I-94 (Arrival/Departure Record) in Unexpired Foreign Passport

I-20 (Certificate of Eligibility for Nonimmigrant, F-1, Student Status)

DS2019 (Certificate of Eligibility for Exchange Visitor, J-1, Status)

_______________________________________________________



              

            5

     (client contact).

Minimum of 100 hours of clinical supervision must be provided by marriage and family therapy supervisor, including

experience assessing and treating clients with more serious problems as cateforized in standard diagnostic nomenclature.

INSTITUTION/PLACE OF EMPLOYMENT

ADDRESS

DIRECTOR OF PROGRAM

MAJOR SUPERVISOR

DID THE PRACTICUM/INTERNSHIP DEAL DIRECTLY WITH THE ASSESSMENT AND TREATMENT OF SERIOUS PROBLEMS?

� YES � NO (See Regulations 36.01 (13) and 36.04.1)

TOTAL HOURS

MONTH

FROM

YEAR

MONTH

YEAR

INSTITUTION/PLACE OF EMPLOYMENT

MONTH

ADDRESS

DIRECTOR OF PROGRAM

MAJOR SUPERVISOR

DID THE PRACTICUM/INTERNSHIP DEAL DIRECTLY WITH THE ASSESSMENT AND TREATMENT OF SERIOUS PROBLEMS?

� YES � NO (See Regulations 36.01 (13) and 36.04.1)

TOTAL HOURS

MONTH

FROM

YEAR

INSTITUTION/PLACE OF EMPLOYMENT

ADDRESS

DIRECTOR OF PROGRAM

MAJOR SUPERVISOR

DID THE PRACTICUM/INTERNSHIP DEAL DIRECTLY WITH THE ASSESSMENT AND TREATMENT OF SERIOUS PROBLEMS?

� YES � NO (See Regulations 36.01 (13) and 36.04.1)

TOTAL HOURS

MONTH

FROM

YEAR

MONTH

YEAR

Total number of hours of MFT experience provided by practica/internships:

South Carolina LMFT Review

Practicum/Internship Verication

Required Courses

(Please refer to pages 9-10 for detailed descriptions)

EACH COURSE CAN ONLY BE USED TO FULFILL ONE REQUIREMENT

1. Theoretical Foundations

(3 courses - 9 semester hours)













Introductory Course (3 semester hours)









2. Clinical Practice

(5 courses - 15 semester

hours total)

























One

or 



Psychopathology (3 semester hours)









; OR

COURSEWORK CATEGORIES

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continued on next page

South Carolina LMFT Review

Coursework Requirements Verication

 

2. 



 Coursework

descriptions must be from the catalogue for the year in which the courses were taken

 



COURSEWORK CATEGORIES

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Diagnostics of Psychopathology (3 semester hours)









current Diagnostic and Statistical Manual of Mental

Disorders



3. Individual Development and Family Relations

(2 courses - 6 semester hours total)





















4. Professional Identity, Legal and Ethical Issues

(1 course - 3 semester hours)











5. Research (1 course – 3 semester hours)











6. Clinical Experience (3 courses - 9 semester

hours total)











10





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REQUIRED BY APPLICANTS FOR LMFT ASSOCIATE

 

2. 







 



                   

              



Check appropriate category:

�  � 

Supervisor’s Name 

Preferred Mailing Address:



City:State:ZIP Code (+4):

Daytime Telephone Number: 

LMFT/S Name:



LMFT/S License Number:LMFT/S License Expiration Date:

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Applicant Name



Social Security Number:

I have applied for licensure by the South Carolina Board of Examiners for Licensure of Professional Counselors, Marriage and

Family Therapists, Addiction Counselors, and Psycho-Educational Specialists, and I am required to make arrangements for board-

approved supervision of my marriage and family therapy practice in order to become board eligible.

 

South Carolina LMFT Review

Plan for Clinical Supervision

of Post-Master’s Clinical Experience

Licensed Supervisor or Supervisor Candidate Verication Information

click to sign

signature

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

















Facility name, address, telephone

and type of work experience

(planned over two years)

Position title

From

month/year

Provide details of your plan to complete the required supervised experience. 

associate



1. Plan for supervised clinical experience of direct marriage and family therapy client contact:

8

Plan for 1,380 hours of direct client contact with

individuals, couples, or groups under the supervision

of an LMFT supervisor, LMFT supervisor candidate, or

other qualied licensed mental health practitioner.

2. Plan for required 120 hours of post-master’s immediate supervision by a licensed marriage and

family therapy supervisor or supervisor candidate:

Total

Hours

From

month/year

A. Individual (a minimum of 100 hours

required to be individual supervision)

B. Group

Total hours of supervision by a licensed

marriage and family therapy supervisor or

supervisor candidate

Total

Hours

From

month/year













SUPERVISION

















REQUIRED (see items 3 and 4 below)

1. 

2.  

associate

3. associate







4. 







I have applied for licensure by the South Carolina Board of Examiners for Licensure of Professional Counselors, Marriage and

Family Therapists, Addiction Counselors, and Psycho-Educational Specialists. I am required to provide documentation of a minimum

of 120 hours of supervision with a licensed professional LMFT supervisor or supervisor candidate of which a minimum of 100 hours

are required to be individual supervision and 20 of these hours can be either group or individual supervision. Please complete the

information below and return the form to me.





 �  � 

















Licensed Supervisor or Supervisor Candidate Verication Information

Continued on next page

INFORMATION BELOW TO BE COMPLETED BY SUPERVISOR (not applicant)

� I verify that the applicant was under my supervision at which time I critiqued the applicant’s counseling and counseling-

related skills based on one or more of the following forms of observation of the supervisee’s LMFT practice 

�  � � 

�  � � 

South Carolina LMFT Review

Confirmation of Clinical Supervision

of Post-Master’s Client Contact in Marriage and Family Therapy

Name, Address, Telephone

and type of work experience

(Minimum of two years of experience)

Total

Years

From

month/year

Applicant’s Employment

1. Conrmation of Supervised Clinical Experience of Direct Counseling Client Contact

8

Total

Hours

From

month/year

8









2. Confirmation of 120 Hours of Post-Master’s Immediate Supervision

Total

Hours

From

month/year







 



 

Recommendation:

I � recommend � do not recommend this applicant for licensure as a South Carolina licensed professional

marriage and family therapist. Associate





Afdavit:

I attest that all information provided herein concerning supervision and work experience is accurate to the best of my

knowledge and is in keeping with the Professional Counselors, Marriage and Family Therapists, Addiction Counselors,

and Psycho-Educational Specialist’s Practice Act. I understand that supervision for licensed Interns and the duration for

associate licensure are for a period of not less than two (2) years.









Required for those applying for licensure by endorsement

PART 1 - TO BE COMPLETED BY THE SOUTH CAROLINA APPLICANT







I hereby authorize the release of licensure information to the Center for Credentialing and Education and the SC Board of

Examiners for Counselors and Therapists.





PART 2 – TO BE COMPLETED BY THE STATE BOARD WHERE THE SOUTH CAROLINA APPLICANT

IS CURRENTLY LICENSED

Board: Please send this form directly to CCE at the address below when completed.





























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





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South Carolina LMFT Review

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INSTRUCTIONS

must







 









 

2

 

22



 82

 





 



 



 



8

2

AssociateAssociate 

 

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



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



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

**CCE accepts complete applications to assure all required forms are complete and reviews the educational

experience of applicants for the South Carolina Licensing Board. All other aspects of the review process are

handled by the South Carolina Licensing Board.

South Carolina LMFT Review

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South Carolina Application and Education Review (Center for Credentialing & Education)

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