AAMFT Associate Licensure Application

Thank you for your interest in joining the AAMFT as an associate member. To apply, please complete the application below. Associate members have completed a graduate degree in a recognized mental health field by the AAMFT and are in the process of earning the clinical experience necessary for licensure as a recognized allied mental health professional. Once you have earned your license in an allied mental health field from an AAMFT accepted state, you are eligible to transfer to the 'Member' category. Associate membership may be held with AAMFT for a maximum of 5 years.

Associate membership is not a guarantee of AAMFT 'Member' Status, nor of state/provincial licensure as a marriage and family therapist. Associate members are responsible for seeking appropriate guidance throughout their training to ensure 'Member' Status and/or licensing requirements are met.

Please be advised that all applications will be processed in seven (7) to ten (10) business days. All applications are hand-processed by members of the AAMFT Member Services team and you will be e-mailed once your application has been processed.

Membership dues and application fees must be paid in US funds and are due when you submit your application for membership, are non-refundable, and subject to change.


Personal Information

Are you now or have you ever been a member of AAMFT? No    Yes
Are you reinstating as a Associate member or wanting to transfer to this membership? Reinstating to Associate    Transferring to Associate
Prefix
First Name (required)
Middle Initial
Last Name (required)
Nickname
Former Name
Preferred mailing address (required):
This address also establishes your AAMFT division membership.
Home    Office
Organization
Office street address
Office city
Office state/Province
Office zip/postal code
Office country
Office phone
Office fax
Home street address (required)
Home city (required)
Home state/province (required)
Home zip/postal code (required)
Home country
Home phone (required)
Home fax
E-mail address (required)
Date of Birth (required)
Gender (required) Male    Female
Degree: Please indicate the degree you would like to have listed in your AAMFT membership record. This should be the degree that qualifies you to practice. Please be reminded of Sections 8.4 and 8.5 of the AAMFT Code of Ethics when listing your preferred degree.
Please be advised that your membership record can reflect only one graduate degree.
Please type degree below.

Allied Mental Health Licensure Information

License Sought (required)
Please type license below.
State in which licensure is sought (required)
Estimated date of full MH licensure (required)
I affirm that I am indeed an applicant working towards MH licensure/certification as described above. Please initial here

Your On-line Listing
The following information is used for our members only on-line directory. The information is only available to the AAMFT membership. The general public does not have access to the information.

Would you like to be listed in the directory? Yes, please list my office address
Yes, please list my home address
No, do not list me in the directory
Online email
Online phone

AAMFT Statement of Professional Ethics and Conduct
Each ethics question is a required field.

1. Are you currently under investigation for alleged violation(s) of the AAMFT Code of Ethics?
2. Have you ever been found in violation of the AAMFT Code of Ethics, or ever entered into any settlement by mutual agreement with the AAMFT Ethics Committee, or agreed to discontinue an act (agreed to cease and desist) at the request of the AAMFT Ethics Committee, or AAMFT legal counsel?
3. Have you ever been found by any other professional association to which you have belonged to have violated its ethical code, have you ever been expelled from or disciplined by any other professional organization, or are you currently under investigation for an ethical violation by any other professional organization to which you belong?
4. Have you ever had your registration, certification or license to practice in the health care industry suspended, revoked, restricted or denied, or has any other disciplinary action been taken against you by any federal, or provincial regulatory body or foreign jurisdiction, or are you presently under investigation by any regulatory body to the best of your knowledge?
5. Have you ever had your privileges to practice health care in a hospital, HMO, etc. suspended or restricted, or has any other disciplinary action been taken against you, on the grounds of unprofessional conduct, incompetence, negligence or unsafe practice?
6. Have you ever been convicted of a felony; or of any misdemeanor which might relate to your qualifications or functions as a therapist or other professional?
7. Has any claim been made against you in a civil suit or any other forum in the past ten years which clearly alleges unethical behavior on your part including, but not limited to, the following examples: sexual intimacy with a client, a dual relationship with a client, violation of confidentiality, and so forth? If yes, please provide an explanation.
8. To avoid punitive action, or in lieu of punitive action, have you ever voluntarily given up privileges, registration, certification or licensure to practice therapy, or agreed to restrict your practice?
If you answered "yes" to any of the above, please provide detailed information below:

Payment Section
*Also includes AAMFT members who are transferring their membership and have a current dues balance.

Transfer to Associate Payment Section
Note: As an AAMFT members transferring to a new membership category you will receive credit for any unused portion of your current membership dues if you have already paid in full for this year. Otherwise, you will be charged the full amount listed below.

Reinstatement to Associate Payment Section
Note: As an AAMFT member reinstating your membership, you will be charged the full amount listed below and your reinstated membership will begin in the month your application is approved and be good for one full year.

Associate Dues $ 146.00
Associate Division Dues ( ) $ 0.00
Processing Fee $ 50.00

Total Amount Due

Total amount due with application $ 0.00

Credit Card Information
(Membership dues and application fees must be paid in US funds and are due when you submit your application for membership, are non-refundable, and subject to change.)

Credit Card Type
Credit Card Number (Please input numbers only)
Expiration Month/Year
Verification Code
(On MasterCard and VISA the Verification Code is the 3 digit # located on the back of your credit card, after your account number. On AMEX it is the 4 digit number above your account # )
Credit Card Billing Address
Cardholder Name

Affirmation/Authorization Statement

I am affirm that the statements made in this application are true. I hereby give permission to the AAMFT to request appropriate information regarding the actions(s) named in the Statement of Professional Ethics and Conduct from the AAMFT Ethics Committee, relevant regulatory bodies, professional associations(s), agencies and/or courts(s). I have read and agree to abide by the AAMFT Code of Ethics.

I also authorize AAMFT to charge the above credit card for national, division dues if applicable, and the application processing fee. Lastly, I understand that membership dues, are non-refundable, and subject to change.

Please initial here (required).

Secure Form! All data is encrypted before it is submitted to AAMFT for your protection!

Thank you for choosing AAMFT as your professional association!

Need help? E-mail us at central@aamft.org or call 703-838-9808.

American Association for Marriage and Family Therapy
112 South Alfred Street Alexandria, VA 22314-3061
Phone: (703) 838-9808 | Fax: (703) 838-9805

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