Massachusetts Licensed Marriage & Family Therapists

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

Individual MFT’s 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 and mail it in. 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.___________________________

______________________________________________ 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 (please include degree): ______________________________________________________________

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

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

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

  MAKE CHECK PAYABLE TO: "FDA/CE Certifications"

and 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
    __ Stamped Self-Addressed Business-Size Envelope
    __ Verification(s) of attendance (copies only)