2020 MFT License Renewal

License Renewal Form

1 Directions

2 Basic Information

3 Additional Licenses & Certifications

4 Continuing Education

5 Renewal Affadavit

6 Review and Submit

Directions
There are four sections to the renewal form:
1. 1. Basic Information
2. 2. Additional Licenses & Certifications
3. 3. Continuing Education
4. 4. Renewal Affadavit (Requires reading some documents- links provided below)
You may save and continue this form for 30 days.
At the bottom of each page of the form, you can click "Next" to move on to the next section, or you may click "Save and Continue Later." If you click to save and continue later, you will receive a link on the screen that can be used from any device to come back and continue.
You can also choose to have the continuation link emailed to you. so you don't lose the specific link for your entry. The tech configurations do not allow the Board to re-generate the save and continue link, so if you can not find it, you will have to start your renewal over again.

Preview your form and review all of the info before you submit it.

Once you enter in all of the requested information, you can preview your submission to make sure everything is correct, before you sign the online renewal form.

To sign the renewal form:
If you are using a phone, tablet, or touch screen computer, you can use your finger to sign. If you are on a computer and you do not have a touch screen, you can use the mouse to sign your name in the appropriate place.

Submit & Pay

Once you click on "Submit," you will taken to the PayPal page to complete payment. You do not need a PayPal account to submit payment. Look beneath the area to enter your login, and you will see a link to click to enter in a debit or credit card to pay.

Submission Confirmation

After submitting your payment, the screen will pause for a moment. Within 5-10 seconds, you will be brought back to the Board website for a confirmation message.

Please make sure you wait for the screen to change with the confirmation message to make sure it went through in the system.

You will receive a copy of your submission, along with your new PDF that updates your license expiration date. Please save that PDF. The PDF will no longer be available for download on the verification page of the website. Online verification will still be there- but there is no option to download your data on a PDF. Once the Board has reviewed and approved your information, it will appear on the verification page of the website.

You may use the buttons at the top of this form to
navigate back to this screen at any time.

Save and Continue Later

Personal Contact Information
Name*Enter your name as it appears on your MFT license
First Last
Email*The Board will send a confirmation notification, receipt, follow-up information, or any questions they have to this email address. Check your spam/junk folder if you do not receive a notification after submitting this form.
Enter Email Confirm Email
Phone*
Last 4 of SSN*NC law requires professional licensing boards to keep a list of tax ID numbers. Entering the last 4 here allows the Board to match renewals to the full SSN submitted at the time of application.
Home Address*
Home City State Zip*
NC County of Residence*
Professional Contact Information
Have you gone through this Board to create a Professional Corporation (PC) or Professional Limited Liability Corporation (PLLC)?*
- Yes
- No
- Not anymore. It was dissolved.
Incorporation NameList the name of your MFT PC/PLLC that you have on file with the Board.
2nd Incorporation NameList the name of your MFT PC/PLLC that you have on file with the Board.
Tax ID/EIN Number (if applicable)
Employer Name*If you are not working at this time, write: student or not working (as applicable)
Business Address*Put N/A if you are not working
Business City State Zip*Put N/A if you are not working
MFT License Information
You may need to refer to the current information attached to your North Carolina MFT license. You will find your license number, the date you were initially licensed, the expiration date, your license type, and if you have a public record currently connected to your license are all available on this website at: https://www.ncbmft.org/verify/
NC MFT License Number*
License Type*If you are an associate licensee (i.e. you currently have an AAMFT Approved Supervisor), select LMFTA.
- LMFTA
- LMFT
Initial License Date*Found on your current license verification PDF
MM
DD
YYYY
License Expiration Date*List the expiration date currently listed for your license . Check the current verification page on the website if you are unsure.
MM
DD
YYYY
Do you currently have a disciplinary record (i.e. ethical complaint, consent order) connected to your MFT license?*Check the verification page on this site if you are unsure about your MFT license status in NC. A disciplinary record occurs when there has been evidence to prove that an ethical or legal violation has occured. You would have been notified by the Board and had interaction with the Board's attorney to have a signed consent order in place.
- Yes
- No
AAMFT Supervisor Name*List the name of your current AAMFT-approved supervisor
AAMFT Approved Supervisor's Email*Enter your AAMFT approved supervisor's email address here. They will receive a PDF copy of your renewed license.
Additional AAMFT Supervisor NameSome LMFTAs have a primary and a secondary AAMFT Approved Supervisor. If you do, list their name here.
First Last
Additional AAMFT Approved Supervisor's EmailIf you have an additional AAMFT Approved Supervisor, enter their email address here. They will receive a PDF copy of your renewed license.
Workplace Supervisor's NameIf you an LMFTA, list the name of your supervisor at work. This may or may not be the same as your AAMFT Approved Supervisor. If you do not have a supervisor or anyone who oversees you at your workplace, write none in each space.
First Last
Workplace Supervisor's EmailList the email address of your workplace supervisor.
If you would like the system to send your workplace supervisor a copy of your updated license verification information once you complete the renewal process, please check yes below.
- Yes
- No

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Additional MFT and other Mental Health Related Licenses
Do you currently hold any other mental health, health care, or related licenses in North Carolina?*
- Yes
- I plan to apply for additional licenses in NC.
- I am in the application process for additional licenses in NC.
- No
Do you currently hold any other mental health, health care, or related licenses in another state?*
- Yes
- I plan to apply for additional licenses in another state.
- I am in the application process for additional licenses in another state.
- No
Have you ever held any other mental health (or related) licenses in North Carolina?*
- Yes
- No
Have you ever held any other mental health (or related) licenses in another state??*
- Yes
- No
Do you have any open ethical complaints related to your professional work in this state or in any other state?*
- Yes
- No
- Third Choice
Please provide a brief explanation of the open ethical complaint. Be sure to include the state and the Board/agency involved in this matter.*
If you do have an open ethical complaints, and you would like to provide any additional documentation to the Board, you may upload that here.
Drop files here or
Additional Licenses and Certifications
List the name of the license/certificate and include the state or group who issued it in the name. For example: South Carolina Licensed and Family Therapist, National Board Certified Counselor, National Council on Family Relations Certified Family Life Educator.
License/Certificate Name (include state/group who issued)*
License/Certificate Number
Issued Date
License/Certificate Expiration Date*
Second Additional License/Certificate
License/Certificate Name (include state/group who issued)
License/Certificate Number
Issued Date
Expiration Date
Third Additional License/Certificate
License/Certificate Name (include state/group who issued)
License/Certificate Number
Issued Date
Expiration Date

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Continuing Education Courses
All courses entered here must have been completed between July 1, 2019 and June 30, 2020.* You must complete 20 contact hours of continuing education each year. Of those 20 hours, at least 3 hours must be in ethics. Applications without an ethics course will not be accepted, and your renewal will not be accepted. Courses completed prior to July 1, 2019 will not be counted towards your renewal requirements, even if they were completed after you renewed for the 2019-2020 renewal year.
*First Time Renewal
If this is your first time renewing your license, then your coursework may be counted from BEFORE July 1, 2019. Your first license allows you to have a minimum of one full calendar year before you renew. You are able to list and use continuing education contact hours and/or supervision that occured from the date your license was first issued through the date you submit your renewal or June 30 (which happens first). Consult with your supervisor if you have additional questions, or refer to the letter that came with your license.
Ethics Courses
List your ethics courses under this section. If you have more ethics courses and run out of space, list those in the other section of the form for additional coursework. You need a minimum of 3 hours of MFT/mental health ethics each year. Most people complete these with one course. There are additional spaces if you needed more than one course to complete the required 3 hours. You do NOT need 3 separate courses for ethics- just 3 contact hours of continuing education. If you enter in 3 hours of ethics in the first ethics course section, you do NOT need to list any other courses under ethics. You may list your MFT Content courses, supervision, or courses that you presented in the next section.
Ethics Course 1
Ethics Course 1 Title*
Ethics Course 1 Date*
MM
DD
YYYY
Ethics Contact 1 Hours*
Please enter a number from 0 to 40.
Ethics Course 1: Continuing Education Content Type*
Where did you complete the contact hours?*
- In person
- Online
- Other
Ethics Course 2
Ethics Course 2 Title
Ethics Course 2 Date
MM
DD
YYYY
Ethics Contact 2 Hours
Please enter a number from 0 to 40.
Ethics Course 2: Continuing Education Content Type
Where did you complete the contact hours?
- In person
- Online
- Other
Ethics Course 3
Ethics Course 3 Title
Ethics Course 3 Date
MM
DD
YYYY
Ethics Contact 3 Hours
Please enter a number from 0 to 40.
Ethics Course 3: Continuing Education Content Type
Where did you complete the contact hours?
- In person
- Online
- Other
Additional Coursework
How many more continuing education COURSES (not hours) do you have to enter in to meet the minimum requirements for licensure renewal (20 total contact hours, with three of those being in mental health ethics). You can come back and adjust this answer to see more places to list courses, if needed.
Course 2
Course 2 Title
Date of Course 2
MM
DD
YYYY
Course 2 Contact Hours
Please enter a number from 0 to 40.
Course 2: Continuing Education Content Type
Where did you complete the contact hours?*
- In person
- Online
- Other
Course 3
Course 3 Title
Date of Course 3
MM
DD
YYYY
Course 3 Contact Hours
Please enter a number from 0 to 40.
Course 3 Continuing Education Content Type
Where did you complete the contact hours?*
- In person
- Online
- Other
Course 4
Course 4 Title
Course 4 Date
MM
DD
YYYY
Course 4: Contact Hours
Please enter a number from 0 to 40.
Fourth Course: Continuing Education Content Type
Course 5
Course 5 Title
Course 5 Date
MM
DD
YYYY
Course 5: Contact Hours
Please enter a number from 0 to 40.
Course 5: Continuing Education Content Type
Course 6
Course 6 Title
Course 6 Date
MM
DD
YYYY
Course 6: Contact Hours
Please enter a number from 0 to 40.
Course 6: Continuing Education Content Type
Course 7
Course 7 Title
Course 7 Date
MM
DD
YYYY
Course 7: Contact Hours
Please enter a number from 0 to 40.
Course 7: Continuing Education Content Type
Course 8
Course 8 Title
Course 8 Date
MM
DD
YYYY
Course 8: Contact Hours
Please enter a number from 0 to 40.
Course 8: Continuing Education Content Type
Course 9
Course 9 Title
Course 9 Date
MM
DD
YYYY
Course 9: Contact Hours
Please enter a number from 0 to 40.
Course 9: Continuing Education Content Type
Course 10
Course 10 Title
Course 10 Date
MM
DD
YYYY
Course 10: Contact Hours
Please enter a number from 0 to 40.
Course 10: Continuing Education Content Type
Course 11
Course 11 Title
Course 11 Date
MM
DD
YYYY
Course 11: Contact Hours
Please enter a number from 0 to 40.
Course 11: Continuing Education Content Type
Course 12
Course 12 Title
Course 12 Date
MM
DD
YYYY
Course 12: Contact Hours
Please enter a number from 0 to 40.
Course 12: Continuing Education Content Type
Course 13
Course 13 Title
Course 13 Date
MM
DD
YYYY
Course 13: Contact Hours
Please enter a number from 0 to 40.
Course 13: Continuing Education Content Type
Course 14
Course 14 Title
Course 14 Date
MM
DD
YYYY
Course 14: Contact Hours
Please enter a number from 0 to 40.
Course 14: Continuing Education Content Type
Course 15
Course 15 Title
Course 15 Date
MM
DD
YYYY
Course 15: Contact Hours
Please enter a number from 0 to 40.
Course 15: Continuing Education Content Type
Course 16
Course 16 Title
Course 16 Date
MM
DD
YYYY
Course 16: Contact Hours
Please enter a number from 0 to 40.
Course 16: Continuing Education Content Type
Course 17
Course 17 Title
Course 17 Date
MM
DD
YYYY
Course 17: Contact Hours
Please enter a number from 0 to 40.
Course 17: Continuing Education Content Type
Course 18
Course 18 Title
Course 18 Date
MM
DD
YYYY
Course 18: Contact Hours
Please enter a number from 0 to 40.
Course 18: Continuing Education Content Type
Course 19
Course 19 Title
Course 19 Date
MM
DD
YYYY
Course 19: Contact Hours
Please enter a number from 0 to 40.
Course 19: Continuing Education Content Type
Total Continuing Education Contact Hours
Total Ethics Hours
Total Continuing Education Hours (Including Ethics)*

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MFT Renewal Affadavit
DIRECTIONS: Read each statement below. Select the truthful answer for each of them. Attach any statements, supporting documentation, or information as directed during the entry process. Answering these statements dishonestly can jeopardize your license. Acknowledgement of situations does not mean you will lose your license. The Board prefers ethical and honest disclosure of situations, rather than omission of situations.
Affirmation 1
Affirmation 1: I affirm that since my last renewal, I have not been convicted or pled nolo contendre to a misdemeanor or felony, or had any disciplinary action taken by any regulatory or licensing board in North Carolina or any other state except as explained in the attached statement/documentation (if necessary). Please include (if applicable) a copy of any court records or statement of any current charges that may be pending against you before any court, Board, agency, or professional organization.*
- I affirm I have not been convicted, pled nolo contendere to a misdemeanor or felony, or had any disciplinary action taken.
- I do not affirm the above statement. I have attached additional documentation to explain.
Affirmation 1 Supporting Documentation*
Drop files here or
Affirmation 2
Affirmation 2: I affirm that I have completed at least 20 hours of continuing education coursework as stated in the Continuing Education section.*
- I affirm that I have completed at least 20 hours of continuing education.
- I do not affirm that I have completed at least 20 hours of continuing education.
Affirmation 3
Affirmation 3: I affirm that my ability to perform my professional responsibilities is not impaired in any way or by the use of alcohol, prescription or non-prescription drugs, or other controlled substances.*
- I affirm that my ability to perform my professional responsibilities is not impaired in any way.
- I do not affirm that my ability to perform my professional responsibilities is impaired in any way. I have attached additional documentation to explain.
Affirmation 3 Supporting Documentation*
Drop files here or
Affirmation 4
You will need to read over the links below to properly affirm in the next question.
Affirmation 4: I affirm that I have reviewed the North Carolina Marriage & Family Therapy General Statutes and Administrative Code and Code of Ethics (see links just above).*
- I affirm that I have reviewed the referenced materials.
- I do not affirm that I have reviewed the referenced materials.
Affirmation 5
You will need to read over the link below to properly affirm in the next question.
- AAMFT Code of Ethics
Affirmation 5: I affirm that I have not violated any of the adopted North Carolina Marriage & Family Therapy Ethical Codes (linked just above).*
- I affirm that I have not violated the ethical codes adopted by the Board.
- I do not affirm that I have not violated the ethical codes adopted by the Board. I have attached additional information to explain.
Affirmation 5 Supporting Documentation*
Drop files here or
Affirmation 6
Affirmation 6: I understand that renewal of my license is subject to a Continuing Education audit which will require me to verify the courses submitted for renewal; and I hereby agree to fully comply with any NC MFT Licensure Board audit request.*
- I agree to comply with any audit request.
- I do not agree to comply with any audit request.
Affirmation 7
Affirmation 7: I understand that all information submitted by me or at my request is accurate, and I give permission to the North Carolina Marriage & Family Therapy Licensure Board to verify and/or further investigate any such information, as it may deem appropriate. I understand that any material omission or misrepresentation in my submission shall be grounds for action by the Board against my MFT license.*
- I affirm that all information submitted by me is accurate.
- I do not affirm that all information submitted by me is accureate. I have attached additional documentation to explain.
Affirmation 7 Supporting Documentation*
Drop files here or
Affirmation 8
You will need to read over the link below to properly answer the question below. You will need to select two answers below.
- Employee Fair Classification Act Public Notice Statement
Affirmation 8: I certify that I have read and understand the "public notice statement- Employee Classification" maintained by the N.C. Industrial Commission, Employee Classification Section. Further, I certify that I have not been investigated for employee misclassification within the past twelve (12) months for initial renewals or since my last renewal.*Check all that apply.
- I certify that I have read the public notice statement referenced above.
- I certify that I have not been investigated for employee misclassification within the past 12 months or since my last renewal.
- I do not certify that I have read the public notice statement referenced above.
- I do not certify that I have not been investigated for employee misclassification.
Affirmation 8 Supporting Documentation*
Drop files here or

Save and Continue Later

Review & Submit
Review the information displayed below to ensure everything is correct. If you need to change anything, use the navigation section just above to move back to adjust. If everything is correct, proceed to the signature and payment section to submit your license renewal. The signature field will not appear if any of the renewal form is incorrect - such as the year not correctly entered as 4 digits, not enough continuing education hours or affirmations are not checked. You will need to go back through the form to make sure everything is correct, and you have met all the requirements.
{all_fields}
How to Submit:
1. Sign below.
2. Enter the date
3. Click submit
4. Enter your payment.
5. While you are entering your payment information, you may receive an email confirming the submission of your renewal form. The payment has not been entered and gone through until you get to the confirmation page in the next step, so please continue submitting your payment information.
6. You do not need a PayPal account to complete the payment. As part of the move to go green, the Board is only accepting payments online. If you would like to pay from your credit/debit card, click on the link that displays below the option to login to a PayPal account.
7. Wait for the screen to bring you back from PayPal to this site
8. You will then see a confirmation message to ensure you that your renewal form went through.
Signature*Use your finger if you are completing this on your phone, tablet, or a touch screen computer. Use the mouse if you are using a computer without a touch screen feature.
Today's Date*
License REINSTATEMENT Fee for licenses expired as of 9/1/20*
Price: $200.00
Annual PC/PLLC Renewal Fee*If you have a PC/PLLC through this Board, you need to pay this annual fee.
Price: $25.00
Total
$0.00
License Active Until
Total
$0.00
Product Name
Price: $0.00 Quantity:
Option
Name
This field is for validation purposes and should be left unchanged.

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License Renewal Form

Directions

There are four sections to the renewal form:

1. Basic Information

2. Additional Licenses & Certifications

3. Continuing Education

4. Renewal Affadavit (Requires reading some documents- links provided below)

Marriage & Family Therapy General Statutes

North Carolina Administrative Code for Marriage & Family Therapy Licensure Board

AAMFT Code of Ethics

Employee Fair Classification Act Public Notice Statement

You may save and continue this form for 30 days.

Preview your form and review all of the info before you submit it.

To sign the renewal form:

Submit & Pay

Submission Confirmation

You may use the buttons at the top of this form to navigate back to this screen at any time.

Personal Contact Information

Professional Contact Information

MFT License Information

Additional MFT and other Mental Health Related Licenses

Additional Licenses and Certifications

Second Additional License/Certificate

Third Additional License/Certificate

Continuing Education Courses

*First Time Renewal

Ethics Courses

Ethics Course 1

Ethics Course 2

Ethics Course 3

Additional Coursework

Course 2

Course 3

Course 4

Course 5

Course 6

Course 7

Course 8

Course 9

Course 10

Course 11

Course 12

Course 13

Course 14

Course 15

Course 16

Course 17

Course 18

Course 19

Total Continuing Education Contact Hours

MFT Renewal Affadavit

Affirmation 1

Affirmation 2

Affirmation 3

Affirmation 4

Affirmation 5

Affirmation 6

Affirmation 7

Affirmation 8

Review & Submit

How to Submit:

Confirmation

You may use the buttons at the top of this form to
navigate back to this screen at any time.