MyMFT 2024 Membership Application & Renewal Form

MEMBERSHIP CATEGORY

NOTE: It is highly recommended that you refer to the MyMFT Membership Guidelines to ensure your membership eligibility.

Membership Type

1. Clinical Member

Credentialed mental health professional actively working with couples and families

2. Associate Member

Credentialed mental health professional NOT actively working with couples and families

3. Affiliate or Student Member

Not a mental health professional but interested in the field OR Master's degree student in the field of mental health

ANNOUNCEMENT!

Duration of Membership and Membership Renewal
The MyMFT membership runs on a calendar year starting from 1st January until 31st December of the year.

Application for a one-year membership: Membership Approval Date till 31st December 2024.
Application for a two-year membership: Membership Approval Date to 31st December 2025.

Application for a one-year renewal : Renewal Date to 31st December 2024. Application for a two-year renewal : Renewal Date to 31st December 2025.

Membership Categories and Fees for One (1) Year:

1. Clinical Member: RM150.00
2. Associate Member: RM130.00
3. Affiliate or Student Member: RM100.00

+ One-time Application fees: RM50.00 [New member only]

For new members please include in the payment for:

1. One-time Application fee of RM50.00

2. Select your membership type

Direct Banking
Account Name: Association for Marriage and Family Therapy Malaysia
Bank: CIMB Bank Berhad
Account #: 800-804-2946

A 2% processing fee is charged to refund requests.

NOTE: Please prepare all the necessary documents and payment slips before getting started with the application form.

If you have any questions in filling up this form, please email us at membership@mymft.org

PERSONAL INFORMATION

Full Name (Include Designation e.g. Prof., Dr., Mr., Ms.)*

First NameLast Name

E-mail*

example@example.com

Type of Application*

If you are renewing your membership, are all the information the same from your last application?*

MyMFT Membership No.:*

ex. 23

MyMFT Membership Type*

Please select your membership type

Current Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

NRIC/Passport No.*

Current Phone Number*

Area CodePhone Number

Date of Birth*

If you are a mental health practitioner, you are currently practicing as a*

licensed and registered counsellorclinical psychologistpsychiatristothers

License Number (Kb, Pa)/MMC number/ Registration Number with MSCP/Other Licensing Body Out of Malaysia*

e.g. Licensed & Registered Counsellor (KB, PA), Clinical Psychologist (MSCP 1234)

University Name (For Student Member Only)

Organization/Professional Website

Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

DOCUMENT GUIDELINES

Copy of Your Malaysian IC or passport*

Updated Resume (PDF Format)*

Copies of Relevant Degree Certs or Transcripts*

Updated Licensing/Registration Document (1. Counselor - License from Lembaga Kaunselor Malaysia; 2. Psychiatrist - Annual Practicing Cert from MMC and registration with National Specialist Register; 3. Clinical Psychologist - Certificate with Malaysian Allied Health Professions Council and Malaysian Society of Clinical Psychologist); 4. Other licensing body out of Malaysia *

Post Graduate Certificate Specializing in MFT*

Verification of Clinical Supervision and/or Clinical Practice in Marriage and Family Therapy *

Other Professional Memberships

ACADEMIC/CLINICAL REFERENCES

Academic/Clinical Referrer 1*

First NameLast Name

Profession*

e.g. Licensed and Registered Counsellor

Professional Licensing Body*

e.g. Lembaga Kaunselor Malaysia

Email*

example@example.com

Current Phone Number

Area CodePhone Number

Academic/Clinical Referrer 2*

First NameLast Name

Profession*

e.g. Licensed and Registered Counsellor

Professional Licensing Body*

e.g. Lembaga Kaunselor Malaysia

Email*

example@example.com

Current Phone Number

Area CodePhone Number

SUPERVISOR'S INFORMATION: CLINICAL SUPERVISOR TRAINED IN MFT

Name of Supervisor*

Email Address*

Type of License of Supervisor*

MEMBERSHIP FEES

Membership Type*

[New Member Only] One-time Application FeeFirst time applying for new members

50.00MYR

Clinical Member [1 Year] (Approval Date to 31st December 2024)(1-year membership)

150.00MYR

Associate Member [1 Year] (Approval Date to 31st December 2024)(1-year membership)

130.00MYR

Affiliate or Student Member [1 Year] (Approval Date to 31st December 2024)(1-year membership)

100.00MYR

Clinical Member [2 Year] (Approval Date to 31st December 2025)(2-year membership)

300.00MYR

Associate Member [2 Year] (Approval Date to 31st December 2025)(2-year membership)

260.00MYR

Affiliate or Student Member [2 Year] (Approval Date to 31st December 2025)(2-year membership)

200.00MYR

Total

0.00MYR

MyMFT Newsletter Subscription and Opt-in for MyMFT Database

MyMFT produces newsletter every now and then to provide latest updates and family therapy related stories, news and upcoming initiatives or events. By clicking YES, I voluntarily agree to subscribe and receive MyMFT newsletters with my registered email. I understand that I can unsubscribe from the email subscription anytime without any consequences.

Proof of Payment*

BACKGROUND CHECK

Please answer the questions below honestly.

Disclaimer: The MyMFT Board reserves the right to reject your application should any documents or information provided be found to be falsified

Have you ever been convicted of a crime?*

YesNo

Have you ever been subjected to any professional disciplinary action?*

YesNo

Do you have any pending disciplinary action against you?*

YesNo

If you answered YES to any of the questions above, please provide appropriate information about the charges laid against you.

Please provide supporting documentation about the charges laid against you.

MyMFT Newsletter Subscription and Opt-in for MyMFT Database

MyMFT produces newsletter every now and then to provide latest updates and family therapy related stories, news and upcoming initiatives or events. By clicking YES, I voluntarily agree to subscribe and receive MyMFT newsletters with my registered email. I understand that I can unsubscribe from the email subscription anytime without any consequences.

By clicking YES, I agree to give MyMFT full permission to send me MyMFT newsletters, marketing or promotional materials for membership and events to my registered email. I understand that I can unsubscribe anytime.*

Yes

ACKNOWLEDGEMENT

By clicking on YES, I am agreeing that all information provided in this application is true and accurate.*

Yes

Signature*

Full Name and NRIC/Passport No.*

Full Name, 000000-00-0000

Date*

2024 MyMFT Membership Application Form