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Massachusetts Licensed Marriage & Family Therapists

Application for Continuing Education Credit
for Activities Not Previously Certified for LMFT's

Insstructions: Individual MFTÕs may use this form to apply for CE credit for activities you attended that were
not pre-certified by the Mass. Assoc. for Marriage & Family Therapy. Print this form, scan and email
, fax or send
via surface
mail. Make as many copies as you need. Use one copy for each activity you attended.
See Check List at bottom.

 

Name________________________________________ Degree____________ MFT License: State ___ # ________

Address______________________________________________________________ Office tel.___________________________

City_________________________________________State______Zip __________ Home or cell tel.______________________

Email: _______________________________________________________________________________

1. Activity.

Title:_______________________________________________________________________________________________

Sponsoring Organization (name, city & state):_____________________________________________________________

___________________________________________________________________________________________________

Location of Activity (city & state):_______________________________________________________________________

Total CE Hours Granted (exclude meals and breaks):____________        Dates Attended: ________________________

Primary Instructor (include degree): ______________________________________________________________

Instructor qualification (Check at least one):  LMFT in Mass.   2 years experience & licensed mental health prof.

2. Qualification of Activity.  (Qualifying Criteria)

Professional Development
Marriage and Family Therapy, or Theory, or Research, or Training
Other relevant clinical area (see Qualifying Criteria): _________________________________________

3. Verification of Attendance. (check all that apply)
Verification of Attendance: (Submit ONLY copies of your verification with this application.)
Continuing Education certificate of attendance from another mental health profession
Canceled Check, card, or online billing receipt
Hand-outs and/or notes I took during the CE activity
Other: __________________________________________________________        

4. Instructor's request for CE credit:

I was the instructor for the above described activity, and request CE credit for my participation. I understand that I can not count more than 15 hours per renewal cycle. (Submit documentation of course taught, start and end dates, and total hours.)

5. Distance Learning:

I understand that I will be granted no more then 50% of all of my combined required CE credits for any one renewal cycle, from activities that are distance learning, online or self study.

6. Signature: All of the above statements are correct and have been personally verified by me to the extent possible. I understand that this CE certification may become invalid as a result of any false or inaccurate information I may have provided.

___________________________________     _________________________________
Signature                                                                                  Today's Date

 

 

 


 

IF YOU HAVE QUESTIONS:
Please visit: www.mftce.com

fax 508-217-3323
Email: m-vickers@comcast.net

  MAKE CHECK PAYABLE TO: "FDA/CE Certifications"

and Pay Online or mail with applications to:

FDA/CE Certifications

40 Speen St. #106
Framingham, MA 01701

Be sure to enclose the following: (your application cannot be processed without all of the following)
   
__ Fee: $20 for a package of applications,  (include any number of applications, for 1 Licensee, 1 renewal cycle)
   
__ Signature and date on application
   
__ If sending via surface mail, include a stamped self-addressed business-size envelope
   
__ Verification(s) of attendance (copies only)

 


Qualifying Criteria for CE Activities

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