idaho licensing board of professional counselors and marriage

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IDAHO LICENSING BOARD OF PROFESSIONAL COUNSELORS AND MARRIAGE & FAMILY THERAPISTS

Division of Occupational and Professional Licenses

11341 W. Chinden Blvd., Building #4 Boise ID 83714 or

P.O. Box 83720, Boise ID 83720-0063

Phone: (208) 334-3233 Website: https://dopl.idaho.gov

E-mail: cou@ibol.idaho.gov

APPLICATION FOR MARRIAGE AND FAMILY THERAPY AND ASSOCIATE MARRIAGE

AND FAMILY THERAPY LICENSE

The requirements noted below are for general information only, please refer to the laws and rules for complete requirements. Please read

all application questions carefully. Several questions, if answered Yes, require additional documentation. You are required to contact the

source of the required documentation and request that documentation be submitted directly to the Board office. If the source will not

provide the documentation, or the documentation is otherwise unobtainable, you must submit a written explanation and any documents

in your possession that would assist the Board in reviewing your application. All requested information, application fee, and initial

license fee must be provided. Processing will be delayed for applications that do not include a social security number or other

documentation required under Idaho Code § 73-122. All application materials must be submitted to the Board office at least seven days

prior to the next scheduled meeting in order for the application to be reviewed by the Board for final action, per Idaho Code § 67-2609.

Incomplete applications that do not include all the items required (excluding those items that must be sent directly to our office

from an issuing authority) will delay licensure.

NOTE: If you have been licensed in another jurisdiction for more than five years, you must complete the endorsement application to be

considered for licensure by endorsement.

INSTRUCTIONS AND CHECKLIST FOR ALL APPLICANTS:

Completed application, including coursework addendum. All requested information must be provided and the application must be

notarized.

Proof of identification – a clear and readable color copy of a government-issued photo ID such as a passport, military ID, or valid

driver’s license is acceptable.

Proof of successful passage of the Marital and Family Therapy National Examination sent directly to our office from AMFTRB.

Copy of official transcripts sent directly to our office from the issuing authority.

Evaluation and Verification of Supervised Experience form(s) in signed and sealed envelope(s) from all supervisors.

Copy of legal name change, if applicable (marriage license or divorce decree). This is applicable if the name used on any

accompanying documents, such as transcripts or birth certificate, does not match the name on the application.

Attach the required fees.

APPLICATION FEE - $200.00

FEES ARE NOT REFUNDABLE. Please make checks and money orders payable to IDOPL. All returned checks are subject to a $20.00

fee and the application will be invalid

ADDITIONAL ITEMS FOR ASSOCIATE MARRIAGE & FAMILY THERAPY APPLICANTS: See Rule 230

Proof of graduate degree - copy of official transcripts sent directly to our office from the issuing authority.

___COAMFTE

___CACREP-MCFC (Please note: CACREP-MCFC graduates may need additional coursework for the LMFT (see Rule 238)

___Other (must include 27 semester credits or 36 quarter credits of coursework set forth in Rule 238.01b - use coursework

addendum)

Evaluation and Verification of Supervised Experience form(s) in signed and sealed envelope(s) from all supervisors.

___Provide proof of completion of a supervised practicum in no less than a twelve (12) month period as part of the graduate

program. The practicum must consist of 300 hours of direct client contact, 150 of which must be with couples , families or

other systems. Applicants with fewer than these hours must complete the supplemental practicum hours addendum (See

Rule 230.02)

IDOPL-8/20 LMFTA/LAMFT OR LMFT/EXAM/01-100/03-100 2 of 10

ontinued)

ADDITIONAL ITEMS FOR MARRIAGE & FAMILY THERAPY APPLICANTS: See Rule 238

Proof of graduate degree - copy of official transcripts sent directly to our office from the issuing authority.

___COAMFTE

___CACREP/Other (60 semester or 90 quarter credit hours that must include 39 semester or 52 quarter credits of coursework

set forth in Rule 238.01b - use coursework addendum)

Evaluation and Verification of Supervised Experience form(s) in signed and sealed envelope(s) from all supervisors.

___ Provide proof of completion of a supervised practicum in no less than a twelve (12) month period as part of the graduate

program. The practicum must consist of 300 hours of direct client contact, 150 of which must be with couples, families or

other systems. Applicants with fewer than these hours must complete the supplemental practicum hours addendum. (See

Rule 230.02)

___

Proof of completion of at least three thousand (3,000) hours of graduate or post-graduate supervised experience in marriage

and family therapy that meets the requirements in Rule 238.04 including a minimum of two thousand (2,000) post-master’s

direct client contact hours, 1,000 of which must be with couples, families or other systems over a period of not less than

two (2) years.

All

applicants must review the Idaho laws & rules prior to licensure. Please note that according to Section Idaho Code § 54-3400,

you must be licensed to practice. The Board’s Laws and Rules may be downloaded at: https://dopl.idaho.gov

ease keep a copy of this application for your records.

ATTENTION MEMBERS AND SPOUSES OF MEMBERS OF THE ARMED SERVICES

If you are a member of the armed forces, an honorably discharged veteran or the spouse of an active member or veteran of the military,

you are entitled to certain benefits because of your service. Those benefits may include expedited processing of your application and

credit for military training that is relevant to the occupational license/registration for which you are applying. For a full explanation of

eligibility and a comprehensive description of benefits available, see Idaho Code §§ 67-9401-9407

. Additionally, active members of the

military may be eligible for a waiver of renewal fees and other renewal requirements, see Idaho Code § 67-2602A.

te: The applicant’s signature must be notarized. The applicants must declare the answers provided are true in front of a

notary (jurat). The language “subscribed and sworn” must appear before the applicant’s signature. An “acknowledgement”

where the notary only verifies the identity of the applicant is not acceptable.

IDOPL-8/20 LMFTA/LAMFT OR LMFT/EXAM/01-100/03-100 3 of 10

IDAHO LICENSING BOARD OF PROFESSIONAL COUNSELORS AND MARRIAGE & FAMILY THERAPISTS

Division of Occupational and Professional Licenses

341 W. Chinden Blvd., Building #4 Boise ID 83714 or

P.O. Box 83720, Boise ID 83720-0063

Phone: (208) 334-3233 Website: https://dopl.idaho.gov

E-mail: cou@ibol.idaho.gov

MARRIAGE & FAMILY THERAPISTS AND ASSOCIATE MARRIAGE AND FAMILY THERAPY APPLICANTS

I hereby make application for a license to practice as a (check only one box per application):

( ) Associate Marriage & Family Therapist ( ) Marriage & Family Therapist

in the state of Idaho under the provisions of Title 54, Chapter 34, Idaho Code, and provide the following:

1. Fu

ll Name (Mr., Mrs., or Ms.) ____________________________________________________________________

2. Ad

dress of Record ______________________________________________________________________________

(The above address is a public record.) Street City State Zip

3. Ma

iling Address ________________________________________________________________________________

(This will be used as address of record if none provided above.) Street/PO Box City State Zip

4. Dat

e of Birth ______/____/_______ S.S. No. _____/____/______

mm dd yyyy (This is not a public record; required by I.C. § 73-122.)

(Proof of identification – a clear and readable color copy of a government-issued photo ID such as a passport, military ID, or valid driver’s license must be attached.)

5. B

usiness Phone (____)____________ Other(____)____________ E-mail _________________________________

(This number is a public record.) (This number is not public record.) (This is not a public record; required by I.C. § 67-2609.)

6. If

currently licensed as a counselor in Idaho, enter your license number here _______________.

7. Ba

ccalaureate degree from ____________________________ on _____________ in ________________________

Institution date major or program

8. Mas

ter’s degree from ________________________________ on _____________ in ________________________

Institution date major or program

9. Do

ctoral degree from ________________________________ on _____________ in ________________________

Institution date major or program

(This office must receive official college transcripts directly from the school registrar before your application will be processed.)

. Graduate degree program title ___________________________________________________________________

11. A

re you or your spouse an active member or honorably discharged veteran of the United States Armed Services?

(To utilize experience or education gained in the military to qualify you for this license/registration, please attach a copy of your DD-214.) ( ) Yes ( ) No

12. H

ave you passed the National AMFTRB Examination?

( ) Yes ( ) No

(If Yes, official scores must be received by this office directly from AMFTRB before your application will be processed.)

. Have you ever been licensed, certified, or registered in another state or jurisdiction?

( ) Yes ( ) No

. Have you ever had a license or registration revoked, suspended or otherwise sanctioned?

( ) Yes ( ) No

(“Sanction” includes any voluntary or involuntary action that limits, restricts, or attaches conditions to lawful professional practice.

If Yes, a copy of the charges and the final order must be received before your application will be processed.)

15. Ha

ve you ever been convicted of any felony or offense involving moral character?

( ) Yes ( ) No

(If yes, the Criminal Conviction Disclosure Form, official court documents, and probation and parole documents along with any other relevant information must be

received with this application.)

(CONTINUED)

IDOPL-8/20 LMFTA/LAMFT OR LMFT/EXAM/01-100/03-100 4 of 10

DAHO LICENSING BOARD OF PROFESSIONAL COUNSELORS and MARRIAGE & FAMILY THERAPISTS

APPLICATION FOR LICENSE

(continued)

FIDAVIT

pon oath I certify each of the following: (1) the responses and information provided in this application and in the attached

addendum(s) and documentation are true and correct to the best of my knowledge; (2) I am the applicant named in and who has signed

this application; (3) I am a United States citizen or a legal permanent resident or I am otherwise lawfully present in the United States; (4)

I have read and will conform to the Laws and Rules governing the profession for which I am seeking a license or authority to practice;

(5) I acknowledge and agree the use of intentional misrepresentation or fraud in this application or violation of any Laws or Rules

governing the profession for which I am seeking a license or authority to practice shall constitute cause sufficient for denial, suspension,

cancellation or revocation of any license or authority applied for or granted to me; (6) I will provide additional or corrected informati

f material changes occur which would cause responses or information provided in or with this application to be inaccurate or

incomplete; (7) I authorize and direct any person, agency, firm, or other entity to release, upon the request of the Idaho Division o

ccupational and Professional Licenses or its authorized representative, any information, communication, report, record, statement,

disclosure, or recommendation that may have bearing on my eligibility for or maintenance of the license or authority for which I a

applying and hereby release and exonerate any of them from any liability of any kind resulting from the release or collection thereof; and

(8)

authorize the Division of Occupational and Professional Licenses to release to any other regulatory entity in any jurisdiction any

information requested about me that may otherwise be protected or confidential that may have bearing on my eligibility for or

maintenance of any license or authority issued or applied for in this or any jurisdiction and hereby release and exonerate them from any

liability of any kind resulting from the release thereof.

____

__________________________________________________

Signature of Applicant

tate of ______________, County of _________________, ss.

Subscribed and sworn before me this ______ day of _______________________, 20 _____.

____

__________________________________________________

(seal) Notary Public Official Signature

My Commission Expires__________________________________

IDOPL-8/20 LMFTA/LAMFT OR LMFT/EXAM/01-100/03-100 5 of 10

IDAHO LICENSING BOARD OF PROFESSIONAL COUNSELORS and MARRIAGE & FAMILY THERAPISTS

MFT Coursework addendum

List below the graduate courses completed that correspond to the educational areas for marriage & family therapy. (see Rule 238.01.b).

☐ COAMFTE – If you check this box, you are exempt from completing this addendum

☐ CACREP – Marriage, Couple, Family Counseling (for LAMFT you are exempt from completing this addendum; for LMFT, please complete the

addendum.

Please note: This form must be filled out in its entirety.)

If you did not attend either a COAMFTE or CACREP MCFC program, please complete the addendum in its entirety.

Marriage & Family Studies (for LMFT 9 semester or 12 quarter credit minimum is required)

Year

Course Name

Institution

Course #

Hours Earned

Marriage & Family Therapy (for LMFT 9 semester or 12 quarter credit minimum is required)

Year

Course Name

Institution

Course #

Hours Earned

Biopsychosocial Health and Development (for LMFT 9 semester or 12 quarter credit minimum is required)

Year

Course Name

Institution

Course #

Hours Earned

Psychological & Mental Health Competency (for LMFT 6 semester or 8 quarter credit minimum is required)

Year

Course Name

Institution

Course #

Hours Earned

Professional Ethics & Identity (for LMFT 3 semester or 4 quarter credit minimum is required)

Year

Course Name

Institution

Course #

Hours Earned

Research (for LMFT 3 semester or 4 quarter credit minimum is required)

Year

Course Name

Institution

Course #

Hours Earned

IDOPL-8/20 LMFTA/LAMFT OR LMFT/EXAM/01-100/03-100 6 of 10

OTE: Credits may not be counted more than once or in more than one area and cannot be split between categories. The total

credits for all categories must be no less than 39 semester or 52 quarter credits for LMFT and must be no less than 27 semester

credits or 36 quarter credits with no minimum credit requirements for content areas for LAMFT.

Marriage & Family Clinical Practicum

Year

Course Name

Institution

Course #

Hours Earned

Marriage & Family Clinical Internship

Year

Course Name

Institution

Course #

Hours Earned

NOTE: practicum and clinical internship must be done in no less than 12 months.

IDOPL-8/20 LMFTA/LAMFT OR LMFT/EXAM/01-100/03-100 7 of 10

T EVALUATION AND VERIFICATION OF SUPERVISED EXPERIENCE APPLICATION

The Applicant named below is seeking licensure to practice Marriage & Family Therapy in the State of Idaho. The Idaho Board requires the

information below in order to evaluate the extent and quality of the applicant’s supervised experience.

SECTION 1 - To be completed by applicant & reviewed by the named supervisor: (this page must be submitted to

Supervisor with page 2). Please keep a copy for your records. DO NOT submit supervision logs unless requested.

A. Name of supervisor _____________________________________________________________________

B. Applicant’s supervised practice location (facility name and address): _______________________________________

_________________________________________________________________________________________________

C. S

upervisor Contact Phone Number (____)___________________

D. Supervised hours: (check only one):

( ) INTERNSHIP / PRACTICUM / GRADUATE ( ) POST-GRADUATE

E. Dates of practice by applicant at this setting: from ________________ to _________________

F. Total number of direct and indirect hours during period listed in E above: _____________

1. Number of direct client contact hours included in F above: ___________________

2. Number of direct contact hours with couples, families and other systems included in F1 above: ____________

Other systems refers to two or more people who are working on a relationship. It might be a couple, parent and child, siblings, employee and boss, co-workers.

This question refers to situations where applicants have supervised experience with two or more people in the room.

G. Supervision hours during period listed in D above:

1. Individual (not group): Number of hours _________

2. Group supervision: Number of hours _________

H. P

lease describe the nature of the applicant's duties:_______________________________________________________

_________

_________________________________________________________________________________________

_________

_________________________________________________________________________________________

__________________________________________________________________________________________________

_______________________________________ __________________________________________

Printed Name of Applicant Signature of Applicant

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VALUATION AND VERIFICATION OF SUPERVISED EXPERIENCE

(continued)

SUPERVISOR INFORMATION

SECTION 2 - To be completed by the supervisor: (do not complete without reviewing Section 1- if the

hours are entered incorrectly the hours will not be accepted)

tle at time of supervision ________________________________________________________________

Title of professional license, if held _________________________________________________________

State of License ____________________ Professional License Number ___________________________

I attest that during the time I was providing supervision to this candidate, I was a registered supervisor with the Idaho State

Licensing Board of Professional Counselors and Marriage & Family Therapists. ( ) YES ( ) NO

Applicant’s supervised practice location (facility name and address): __________________________________________

_________

________________________________________________________________________________________

H. Please state the quality of the applicant’s performance during the supervised practice period: _____________________

_________

_________________________________________________________________________________________

__________________________________________________________________________________________________

_________

_________________________________________________________________________________________

_________

_________________________________________________________________________________________

I. I have reviewed the applicants hours and they ( ) are or ( ) are not substantially correct.

(If the supervision/contact hours are not correct the hours will not be accepted.)

J. I have reviewed the applicant's statements. They ( ) are or ( ) are not substantially correct.

K. As supervisor, do you have any reservations about the applicant being granted a license? ( ) YES ( ) NO

IF YES, PLEASE SPECIFY (Attach additional sheet if necessary):

___________________________________________________________________________________________________

AFFIDAVIT

I hereby certify under penalty of perjury that the responses provided by both the applicant and myself are true and accurate to the best of

my knowledge and belief, and that I may be required to provide additional information. I further certify that I have reviewed and will

comply with the Idaho Laws and Rules, including the adopted Code of Ethics, governing supervision and the practice of Counseling

and/or Marriage & Family Therapy.

______________________________________ _________________________________________

Printed Name of Supervisor Signature of Supervisor

NOTICE TO SUPERVISOR

Please seal BOTH PAGES of this completed document in an envelope, sign your name across the sealed back flap, and return it to the

applicant. Please be aware this document will become part of the applicant’s file and the applicant has the right to request anything from

the file.

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Addendum for Marriage and Family Therapy Supplemental Practicum Hours

Supplemental hours are post-masters hours only (see Rule 10 and Rule 230)

SECTION 1 - To be completed by applicant & reviewed by the named supervisor: (this page must be submitted to

Supervisor with page 2). Please keep a copy for your records.

A. Applicant name: ___________________________________________________

Name of supervisor (Must be a LMFT) _________________________________________________________

C. Applicant’s supervised practice location (facility name and address): _______________________________________

_________________________________________________________________________________________________

D. P

hone number of supervisor (_____)_____________________

E. The supervision was (mark with an X one only):

( ) IDAHO REGISTERED INTERN ( ) SUPERVISED PRACTICE OTHER JURISDICTION

Registered intern number________

F. Dates of practice by applicant at this setting: from ________________ to _________________

G. Total number of direct client contact hours during the period listed in F above: __________________________

• Number of direct contact hours with families, couples and other systems included in F above ________________

Other systems refers to two or more people who are working on a relationship. It might be a couple, parent and child, siblings, employee and boss, co-workers.

This question refers to situations where applicants have supervised experience with two or more people in the room.

H. Number of individual supervision hours (not group) hours with supervisor during period listed in E above:

(Required ratio 1 hour of supervision for every 10 hours of direct client contact)

Number of hours in person _____________ Number of hours live electronic connection_____________

lease describe the nature of the applicant's duties:_______________________________________________________

_________

_________________________________________________________________________________________

_________

_________________________________________________________________________________________

_________

_________________________________________________________________________________________

_________

______________________________ ___________________________________________

Printed Name of Applicant Signature of Applicant

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Supplemental Practicum Hours

(continued)

SECTION 2 - To be completed by the supervisor: (do not complete without reviewing Section1)

tate of License ____________________ LMFT License Number ___________________________________________

pplicant’s supervised practice location (facility name and address): __________________________________________

_________

________________________________________________________________________________________

I have reviewed the applicant's statements. They ( ) are or ( ) are not substantially correct.

J. A

s supervisor, do you have any reservations about the applicant being granted a license? ( ) yes ( ) no

If yes, please specify (attached additional sheet if necessary):________________________________________________

____

_______________________________________________________________________________________________________

_________

________________________________________________________________________________________

FIDAVIT

I hereby certify under penalty of perjury that the responses provided by both the applicant and myself are true and accurate to the best of

my knowledge and belief, and that I may be required to provide additional information. I further certify that I have reviewed and will

comply with the Idaho Laws and Rules, including the adopted Code of Ethics, governing supervision and the practice of Counseling

and/or Marriage & Family Therapy.

______________________________________ _________________________________________

Printed Name of Supervisor Signature of Supervisor

NOTICE TO SUPERVISOR

Please seal BOTH PAGES of this completed document in an envelope, sign your name across the sealed back flap, and return it to the

applicant. Please be aware this document will become part of the applicant’s file and the applicant has the right to request anything from

the file.