Family Therapy Certification Application Form

Fields marked with an * are required

1. Name

Other Name:
Preferred name and/or titles to appear on certificate:

2. Preferred Mailing Address:

3. Telephone with Area Code:

5. Date of Birth:


7. Education / Training:


OPTIONS FOR CERTIFICATION

The National Credentialing Academy provides applicants with a set of entry options that can be used to become a recognized Certified Family Therapist. Many of the options can be efficiently processed.

OPTION ONE:  State Licensed Marriage and Family Therapist
Process by:

Completion of the CFT application, and copy of state license, or verification of licensure (license in good standing)

OPTION TWO:  Graduation from a CACREP or COAMFTE Accredited Marriage and Family Counseling/Therapy Graduate Training Program
Process by:
Completion of CFT application. Evidence of degree and transcripts. Two professional reference forms.

OPTION THREE:  Clinical Membership in the American Association of Marriage and Family Therapy
Process by:
Completion of CFT application, copy of one’s Clinical membership in AAMFT, or verification of membership  (member in good standing).

OPTION FOUR:  Nationally Certified Counselor (NCC) by the NBCC, Licensed Professional Counselor, Licensed Social Worker, or Licensed Psychologist
Process by:

Completion of CFT application. Copy of licensure or certification. Transcripts and graduate and/or post-graduate coursework, workshops, or training verifying education/training in specific areas in marriage and family counseling/therapy. Post graduate employment/supervision verification in marriage and family counseling/therapy and two professional forms.
or
Graduate from a Master’s Program in Behavioral Sciences: Counseling, Counseling Psychology, Psychology, Social Work, Marriage and Family Studies, or Closely Related Areas:
Process by:

Completion of CFT application. Official transcripts, graduate and/or post graduate coursework, training/workshops verifying education/training in specific areas in marriage and family counseling/therapy. Post graduate employment/supervision verification in marriage and family counseling/therapy and two professional reference forms.

 

10. List all professional licenses, certifications, registrations, or other credentials that you hold.

11. Professional References:  (for entry options 2 & 4 only) List the two persons from whom you shall request a Professional Reference Assessment Form. One reference MUST be from a current or former supervisor of your marriage and family counseling/therapy experience. The second reference may be from a trainer or professional colleague. Neither relatives nor clients may provide references.


12. Professional Experiences: (for entry option 4 only)

A. Dates of employment:

B. Dates of employment:

13. Affirmation of Good Standing:

I HEREBY ATTEST TO, AND CERTIFY THAT, THE FOLLOWING STATEMENTS ARE TRUE, CORRECT AND ACCURATE TO THE BEST OF MY KNOWLEDGE, AND I FURTHER AGREE TO FULFILL THE OBLIGATIONS SET FORTH AS FOLLOWS:

     I understand that any intentional or unintentional failure to provide true and complete responses to this application may result in sanctions by the NCA Board of Ethics Committee.

14. Certification of Accuracy, Agreement, and Release Authorization:

By signing this document, I hereby certify that the information provided in this application is true, accurate and complete to the best of my knowledge and belief.  I understand and agree that the NCA has the right to contact any person, government agency or entity, or organization to review or confirm any information provided in this application.  I further agree to authorize the release of any information requested by the NCA with respect to the review of this application.  I further understand and agree that the NCA has the right to notify pertinent credentialing and professional organizations if it is determined that this application contains false information.

I understand and agree that any certification granted to me by the NCA does not, in and of itself, imply or specify licensure or registration to practice family therapy for a fee or otherwise.  I further understand that if I am granted certification by the NCA and practice, I do so at my own risk.  I hereby release the NCA from any and all liability and claims that may arise from any and all counseling and therapy activity in private practice or otherwise.

I understand and agree that NCA certification and re-certification depends upon my fulfillment of all required criteria and obligations.  I further agree to fully inform the NCA, in a timely manner, if I become the subject of any ethics, disciplinary, criminal, or lesser offenses, complaints or charges.

Upon certification, I understand and agree that professional biographical data is considered to be public information and will be made available in response to consumer/client inquires.  I further agree that, for research and statistical purposes only, data resulting from my application in the NCA certification process may be used in an anonymous/unidentifiable manner.

In the event that my NCA certification is suspended or revoked, I agree to comply with all directives or orders of the NCA Board and Ethics Committee, including the return of all NCA credentialing documents.  I agree to comply with such directives and orders in a timely manner and at my own expense.


Payments mailed should be made to the National Credentialing Academy or NCA.  If applicant does not meet certification requirements, a non-refundable $25.00 application-processing fee is assessed and the remaining fee will be returned to the applicant.

The National Credentialing Academy
13566 Camino De Plata
Corpus Christi, Texas 78418