2020 MFT License Renewal License Renewal Form 1 Directions2 Basic Information3 Additional Licenses & Certifications4 Continuing Education5 Renewal Affadavit6 Review and Submit Directions: There are four sections to the renewal form: Basic InformationAdditional Licenses & CertificationsContinuing EducationRenewal Affadavit (Requires reading some documents- links provided below)Marriage & Family Therapy General StatutesNorth Carolina Administrative Code for Marriage & Family Therapy Licensure BoardAAMFT Code of EthicsEmployee Fair Classification Act Public Notice Statement 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. 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. 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. 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. Personal Contact InformationName* 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. 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 InformationHave 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 Name List 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 workingBusiness City State Zip* Put N/A if you are not workingMFT License InformationYou 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. a 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. Yes No AAMFT Supervisor Name* List the name of your current AAMFT-approved supervisorAAMFT Approved Supervisor's Email* Additional AAMFT Supervisor Name Some LMFTAs have a primary and a secondary AAMFT Approved Supervisor. If you do, list their name here. First Last Additional AAMFT Approved Supervisor's Email Workplace Supervisor's Name First Last Workplace Supervisor's Email 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 Additional MFT and other Mental Health Related LicensesDo you currently hold any other mental health, health care, or related licensed 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 licensed 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 CertificationsList 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 NumberIssued DateLicense/Certificate Expiration Date*Second Additional License/CertificateLicense/Certificate Name (include state/group who issued)License/Certificate NumberIssued DateExpiration DateThird Additional License/CertificateLicense/Certificate Name (include state/group who issued)License/Certificate NumberIssued DateExpiration Date Continuing Education CoursesAll 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 RenewalIf 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.Ethics CourseEthics Course Title*Ethics Course Date* MM DD YYYY Ethics Contact Hours*Please enter a number from 0 to 40.Ethics Course: Continuing Education Content Type*MFT EthicsMFT Therapy ContentCourse PresenterSupervisionWhere did you complete the contact hours?* In person Online Other Course 2Course 2 TitleDate of Course 2 MM DD YYYY Course 2 Contact HoursPlease enter a number from 0 to 40.Course 2: Continuing Education Content TypeChoose...MFT EthicsMFT Therapy ContentCourse PresenterSupervisionWhere did you complete the contact hours?* In person Online Other Course 3Course 3 TitleDate of Course 3 MM DD YYYY Course 3 Contact HoursPlease enter a number from 0 to 40.Course 3 Continuing Education Content TypeMFT EthicsMFT Therapy ContentCourse PresenterSupervisionWhere did you complete the contact hours?* In person Online Other Course 4Course 4 TitleCourse 4 Date MM DD YYYY Course 4: Contact HoursPlease enter a number from 0 to 40.Fourth Course: Continuing Education Content TypeChoose...MFT EthicsMFT Therapy ContentCourse PresenterSupervisionCourse 5Course 5 TitleCourse 5 Date MM DD YYYY Course 5: Contact HoursPlease enter a number from 0 to 40.Course 5: Continuing Education Content TypeChoose...MFT EthicsMFT Therapy ContentCourse PresenterSupervisionCourse 6Course 6 TitleCourse 6 Date MM DD YYYY Course 6: Contact HoursPlease enter a number from 0 to 40.Course 6: Continuing Education Content TypeChoose...MFT EthicsMFT Therapy ContentCourse PresenterSupervisionCourse 7Course 7 TitleCourse 7 Date MM DD YYYY Course 7: Contact HoursPlease enter a number from 0 to 40.Course 7: Continuing Education Content TypeChoose...MFT EthicsMFT Therapy ContentCourse PresenterSupervisionCourse 8Course 8 TitleCourse 8 Date MM DD YYYY Course 8: Contact HoursPlease enter a number from 0 to 40.Course 8: Continuing Education Content TypeChoose...MFT EthicsMFT Therapy ContentCourse PresenterSupervisionCourse 9Course 9 TitleCourse 9 Date MM DD YYYY Course 9: Contact HoursPlease enter a number from 0 to 40.Course 9: Continuing Education Content TypeChoose...MFT EthicsMFT Therapy ContentCourse PresenterSupervisionTotal Continuing Education Contact Hours This section is automatically calculated for you.Total Continuing Education Hours* MFT Renewal AffadavitDIRECTIONS: 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 1Affirmation 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 2Affirmation 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 3Affirmation 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.Marriage & Family Therapy General StatutesNorth Carolina Administrative Code for Marriage & Family Therapy Licensure BoardAAMFT Code of EthicsAffirmation 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 EthicsAffirmation 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 6Affirmation 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 7Affirmation 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 StatementAffirmation 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.* 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 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 make adjustments. If everything is correct, proceed to the signature and payment section to submit your license renewal. The signature field will not appear is certain parts of the renewal form are not correct. You will need to go back through the form to make sure everything is correct and you have meet all of the requirements. {all_fields} HOW TO SUBMIT: Sign below. The signature box is coded to only show up if you have completed all of the required parts of this form correctly. If you do not see it, please go back and review the entire form to make sure everything is correct. Option 1: Sign using your mouse or the touchpad on your computer. Option 2: Sign using your phone or tablet. Option 3: If you are on your computer, click "Save and Continue" option and enter your email address. Open your email on your phone and click the link. Navigate to the "Review & Submit" section, and use your finger on the screen of your phone to sign. Finish the process on your phone. Enter the date Click submit Enter your payment. 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. 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. Wait for the screen to bring you back from PayPal to this site You will then see a confirmation message to ensure you that your renewal form went through.