AAMFT Student Application

Thank you for your interest in joining the AAMFT as a student member. To apply, please complete the application below. Student members of the AAMFT must be enrolled in a graduate or post-degree training program in marriage and family therapy or a related mental health field, that can be reasonably expected to lead towards MH licensure and status as an AAMFT Clinical Fellow or Member. Student membership may be held until you have completed your graduate program or for a maximum period of 5 years, which ever comes first.

Student membership is not a guarantee of eventual status as an AAMFT Clinical Fellow or Member, or of eventual state/provincial licensure as a marriage and family therapist or other allied mental health professional. Student members are responsible for seeking appropriate guidance throughout their training to ensure membership and/or licensing requirements are met.

Please be advised that student degrees and licenses are not listed in member records or correspondence.

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 Student member or wanting to transfer to this membership? Reinstating to Student   
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

Education

Institution name (required)
Program of study (required)
Expected degree/certificate (MA, MS, PhD, etc) (required)
Expected graduation date (required)
I am a student currently enrolled in a graduate program leading to a graduate degree or post-graduate certificate in marriage and family therapy or a related mental health field. 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
Payment includes an application processing fee of $25.00 and the national student dues of $58.00. Division (state/province) membership is automatic when you join and some divisions charge student division dues.

Reinstatement to Student 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.

Student Dues $ 58.00
Student Division Dues ( ) $ 0.00
Processing Fee $ 25.00

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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