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Application to be Granted Continuing Education Credit
for Activities Not Already Certified for LMFT's in Massachusetts

Use this form to apply for CE credit for activities you already attended, that were not pre-certified by the Mass. Association for Marriage & Family Therapy, Inc. Make as many copies of this form as you need. Use one copy for each activity you attended. See check list at bottom.

Name:

______________________________________

Degree____   License # ____   State ___

Home address:

______________________________________

______________________________________

City ________________ State _____ Zip _______

Telephone#'s:

  (w) _________________________

(cell) ________________________________

email:

____________________________________________________________________________

 

Activity Title:



____________________________________________________________________________

Date(s):

Start Date: ________  End Date: ________

 CE hours granted: ___________

Sponsoring Organization: __________________________________________________________________

Address:

____________________________________________________________________________

City:

___________________________________

State____  Zip ________ Country _____________

Primary Instructor: _________________________________

Degree or Qualification: ____________________

 ____ LMFT     ____Other mental health license + 2 years experience

Activity Qualification:  ___ Ethics & Legal   ___ Clinical MFT   ___ MFT Theory  ___ Research

  ___ Supervision & Training   ___ Other relevant clinical (explain) _________________________

Enclosed verification of attendance (copies, not originals):

____ certificate from program sponsor

 ____ certificate from another mental health profession ____ hand outs or notes I took during the CE activity

____ 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 of instruction per renewal cycle.

Attestation: 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 _____________________________________ Date ________________


Enclosures required:   _____ $20.00 application fee for current renewal cycle   ____ stamped, self-addressed envelope

___ verification of attendance

Submit this application to:

FAMILY DEVELOPMENT ASSOCIATES / CE CERTIFICATIONS
40 SPEEN ST., #106
FRAMINGHAM, MA 01701
voice 800-814-9100 ext. 6
fax 508-872-6330
email: m-vickers@comcast.net  |    www.mftce.com