Sponsoring Organization _________________________________________________________________

Contact Person ______________________________________________ Position ______________________

Address ___________________________________________________ Phone (___ )____________________

__________________________________________________________ Fax (___ )____________________

__________________________________________________________ Email: ______________________

Registration web site (URL) _________________________________________________________________

Activity Title ___________________________________________________________________________

Location: _______________________________________________________________________________

Description _____________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Content Justification (see "Criteria for Certification"). Check at least one.

____1. Professional Practice: (from list, below)________________________________________________________

____2. MFT activity (circle all that apply): clinical methods; research methods or reports; theory; training.

____3. Other relevant content (from list, below): _______________________________________________________

Instructor Qualification: (See "Presenter Qualifications" below, for professional license type and qualification #.)

Instructor (primary) _________________ Degree _______ Prof. Lic. Type _____ Qualification #_______

Date ____________ Contact Times _______________________________ CE hours ___

Date ____________ Contact Times _______________________________ CE hours ___

Date ____________ Contact Times _______________________________ CE hours ___

Date ____________ Contact Times _______________________________ CE hours ___

Date ____________ Contact Times _______________________________ CE hours ___ Total Hours ______

State(s): Circle state(s) for which certification is requested: MA / RI

Fee for this application: $ ___________ (see Cover Page and "Information for Providers")

Enclosures: Be sure to enclose a copy of your evaluation form to be completed by participants, a bibliography relevant to this activity, and the required fee.

Signature: All of the above statements are correct and have been personally verified by me. I understand that this CE certification may become invalid as a result of any inaccurate information. Program changes will be reported prior to the start of the activity. I agree to abide by the guidelines for certification in the "Information for Providers" document. As the sponsor, I accept full responsibility for the content and conduct of this activity.

Submit all materials to:

www.mftce.com

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Criteria for Certification

To be certified for MFT Continuing Education, an educational activity must meet certain content and instructor criteria. Activities which meet at least one of the content criteria and one of the instructor criteria will be eligible.

I . Content Criteria

1. Professional Practice activities. These activities enhance clinicians’ ability to understand and function within the legal, economic and regulatory environments, and may include information about practice development, therapist "burn-out", managed care, financial management, mental health and domestic law, expert witness testimony, and /or risk management (among others). All activities, offered within any of the mental health or human service professions are eligible for certification, whether they specifically address MFT’s or not.

2. Marriage & Family Therapy activities. Clinical, theoretical, research, and all other activities will be eligible for certification if they expressly address at least one of the following (a broad definition of "couple" and "family" are intended):
a. methods: clinical or research methods which can be used with couples or families.
b. theory: ideas about how couples and families and organizations function, including how
individuals function within social settings and the impact of these settings on individuals.
c. research or outcomes: methods or review of results: focusing on families and/or the practice
of MFT.
d. training and supervision: learning to teach or supervise other MFT’s (on-going clinical
supervision is excluded).
Generally MFT activities will prominently mention MFT or related issues in the title and/or description. Activities such as human development, psychopathology, disability and clinical models intended for use with individuals can be certified for MFT’s so long as they address either interpersonal processes or specific content areas of concern to MFT’s (see below).

3. All other mental health continuing education activities: The following specific content areas and clinical methods have been identified as also being directly relevant to the practice of MFT. CE activities addressing these issues will be eligible for MFT certification, whether or not they prominently address MFT.

Adoption
ACOA issues
ADHD
Adolescence
Aging
Behavioral medicine
Bereavement
Brief therapy
Chemical dependency
Child abuse and neglect
Co-dependency issues
Divorce, custody and mediation
Domestic violence
Eating disorders
Ethnicity & multi-cultural issues
Fertility
Gay and lesbian issues
Gender identity
Gender issues
Human development
Hypnotherapy
Narrative methods
Organizational behavior
Parenting
PTSD
Psychopharmacology
Psychopathology
Sexuality and sexual dysfunction
Substance abuse and recovery
Solution-focused therapy
Survivors of abuse and trauma

II. Presenter Qualifications:
To be eligible for MFT CE certification, at least one of the instructors or presenters present at each meeting of the activity must meet at least one of the following criteria:
1. Licensed MFT (any state or Canadian province)
2. Clinical Member, or Approved Supervisor or Supervisor-in-Training, AAMFT.
3. Other licensed mental health professional with 2 or more years experience doing MFT.
4. Staff member of an agency providing MFT services, 2 years or more MFT experience.
5. Faculty member of an educational institution teaching MFT.
6. Other qualified professional with experience relevant to this particular activity.
7. Non-professional with relevant experience (enclose explanation).

Professional License Type (for coding on the form):
Marriage & Family Therapist............ MFT Psychiatrist.........................MD
Mental Health Counselor............... MHC Psychologist......................Psy
Nurse............................................. RN Social Worker ....................LICSW or LCSW
Other ...................OTH (explain on form) None ................................ None (explain on form)

www.mftce.com