STATE OF LOUISIANA

LICENSED PROFESSIONAL COUNSELORS BOARD OF EXAMINERS

8631 Summa Avenue, Baton Rouge LA 70809

Phone: 225-765-2515  Fax: 225-765-2514 

APPLICATION FOR LICENSED MARRIAGE AND FAMILY THERAPY

GRANDFATHERING PERIOD 

Verification OF AAMFT CLINICAL MEMBERSHIP

OR ASSOCIATE MEMBERSHIP

 Applicant: Please forward this form to AAMFT

Name of Applicant:  _____________________________________________________________

                              Title   First                                               Middle     Last                                    

Address:  _____________________________________________________________________

                   Street                                                         City             State                         Zip  

AAMFT Member Number: _________________Date Became Member:  ___________ 

Authorization for release of information: I hereby authorize the American Association for Marriage and Family Therapy to release the information requested and furthermore to release any additional information concerning me as may be deemed reasonably necessary in the consideration of my application to the Louisiana Licensed Professional Counselors Board of Examiners. 

Signature of Applicant: _____________________________________Date: _____________           

******************************************************************************

Verification of Membership by AAMFT 

This to certify that the applicant signing this form was issued Member number__________ on [date]____________________ and is a: Current _____   Clinical Member _______ Associate Member ______. 

Has this applicant ever been found in violation of the AAMFT Code of Ethics?

                                    YES                             NO

Has this applicant's membership ever been restricted, suspended, or revoked?

                                    YES                             NO

Is this applicant under investigation for alleged violation(s) of the AAMFT Code of Ethics?

                            YES                              NO 

Please be specific about any disciplinary action taken against this applicant:

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Person Verifying:     _______________________________________________________________

                                     Signature                                                                      Title

Please return this form directly to the LPC Board at the address at the top. Thank you.