The Master of Arts in Marriage and Family Therapy (MAMFT) Program Student Acknowledgment Form

Student First Name:*

Student Last Name:*

Student ID Number:*

Student's E-mail (university-issued email)*

example@o365.ncu.edu

Instructions: Review the resoures in the links below and acknowledge your understanding.

Link to: MAMFT Program Handbook

Link to: MAMFT Clinical Training Handbook

Link to: MAMFT State Information

Acknowledgements*

	Yes
1. I agree to abide by all University requirements as outlined in the current University Catalog and as updated throughout my time the university.
2. I understand that I must take full responsibility for ensuring that my degree program meets the licensing requirements of my intended state of licensure board (where applicable).
3. I have read and understand the program policy statement that if I have been convicted of a felony or misdemeanor prior to or subsequent to admission into the MFT program, I am required to immediately inform the Program Director of the MAMFT Program. I understand that such conviction may result in my dismissal from the program.
4. I understand that if I am diagnosed, treated, or admitted to a hospital or other facility for the treatment of any psychotic disorder (e.g. bipolar disorder, schizophrenia, paranoia, etc.); suicide attempt(s); substance abuse; or the illegal use of any controlled substance, habit-forming drug or prescription medication I am required to immediately inform the Program Director as this may interfere with my ability to competently and safely perform the essential functions of the MFT profession. I further understand that if this occurs I will be required to provide a letter from my treating physician or licensed mental health professional indicating I am compliant with treatment and currently able to practice safely and competently.
5. I understand that a minimum cumulative GPA of 3.0 must be maintained throughout the program and is required for graduation. I understand that I must earn a passing grade in not less than 66.6% of total credit hours attempted, and I must complete this program within 6 years.
6. I understand that I will be provided with information about the Clinical Preparation Process (CPP) after I have successfully completed three courses.
7. I understand that I will not have access to the CPP until I've enrolled in my 6th course. I understand I am expected to complete the entire CPP within the expected time limit (prior to starting my clinical courses). Failure to do so will result in a delay in the start of my clinical training and graduation date.
8. I understand that I may be placed on academic probation or other corrective actions by the University or Department for unsatisfactory academic progress or for unsatisfactory performance in other training domains, including, but not limited to, CPP elements, clinical training placements, professional or ethical violations or concerns. If I am placed on academic probation, I understand that I am expected to follow any guidelines or plan provided (if applicable); completing all required elements of the plan.
9. I understand that if I violate the University's student Code of Conduct and/or Academic Integrity policy I may be subject to immediate administrative dismissal, and would not qualify for readmission to University.
10. I understand that as a student in this program and as a student therapist I am required to conduct myself with professionalism and respect for all who I engage with connected to my educational experience during my time the program and in accordance with the most current edition of the AAMFT Code of Ethics and the Program’s Code of Conduct.
11. I understand it is my responsibility to secure an appropriate clinical training site and qualified local supervisor (AAMFT Approved Supervisor or State-Approved supervisor) as outlined in the Program and Clinical Training Handbooks. As indicated in my application and in this acknowledgement form, I understand that failure to find a qualified site or supervisor will make completion of the program impossible.
12. During my clinical training, I understand I am responsible for keeping an accurate record of all of my client contact and supervision hours for review by my local supervisor(s), the University MFT faculty, and for the purpose of applying to state (or other) licensing boards.
13. I understand that in order to complete some of the course requirements, including the online supervision process used during the clinical training courses, I will be required to participate in periodic (weekly during clinical training) online video conferencing meetings throughout my time in the program. In addition, I understand I am required to record some of my therapy sessions with clients (using a HIPAA-compliant device) to share during online university supervision sessions, as well as have all of my clients sign a standard informed consent document that discloses the video recording of sessions and requests permission for recording, transmission, and supervision of the sessions during the university supervision group . I understand that the Director of Clinical Training must approve any exceptions to this requirement.
14. I understand that I am required to complete at least 300 direct client contact hours (at least half of these hours must be relational - working with couples, parents and children together, or whole families together). I understand that I am required to complete at least 100 hours of university supervision, 52 of hours of individual supervision with the approved Local Clinical Supervisor (100 for California students), and at least 50 hours of university observable data supervision (either video/audio recording of client sessions). I also recognize that all hours that are required must occur over at least a 52-week period. I understand that I will need to indicate the hours needed to graduate based on my licensing state requirements and may need to complete additional hours beyond the program requirements. I also understand I am expected to review the relevant Program Handbook and Clinical Training Handbook for detailed information regarding these requirements.
15. I understand I am required to maintain weekly supervision with my approved Local Clinical Supervisor and that I must participate in University faculty group supervision each week while I am actively seeing clients, or more frequently if required by my state rules and regulations or by the university.
16. I understand that prior to beginning any clinical training, I am required to submit proof of active professional liability insurance.
17. I have read and agree to abide by the Confidentiality Statement in the Program Handbook and Clinical Training Handbook.
18. I understand that faculty Authorized Site Representatives, and Local Clinical Supervisors work collaboratively for the benefit of the students and the MFT program. Therefore, I understand that all parties, including Training Team and staff, may discuss and disclose information concerning my performance as a student and as a therapist-in-training. This information, including information that I may share in courses or in supervision, will only be disclosed to other MFT clinical faculty, supervisors, and staff as needed (deemed pertinent for my personal and/or the MFT program's benefit by faculty, supervisors, and staff), except where otherwise outlined in the Program or Clinical Handbooks
19. I have read the Marriage and Family Therapy (MFT) Program Handbook relevant to my program and understand all of the information contained therein. I have been given an opportunity to ask questions about the Handbook and understand that if I have concerns about it or the contents of it, I may speak with the Program Director before signing this statement. Furthermore, I agree with the information provided in the MFT Program Handbook and agree to abide by the conditions stated therein.
20. I have reviewed the MAMFT Program's mission, goals and student learning outcomes in the Program Handbook and understand that I may directly contact the Program Director (MFSDepartment@nu.edu) with any questions or feedback that I have.

Please read and acknowledge the following statement by clicking the box below.*

I acknowledge that, as a student in the MAMFT program, I will be asked to think broadly and critically about issues related to diversity, equity and inclusion. I understand that my course work, readings, and assignments, as well as material related to course design and implementation, reflect the University’s commitment to inclusion and the reflection of a diverse population.I understand that I will be asked to consider my own identities, biases, privileges, and beliefs surrounding equity and inclusion. Furthermore, as a student and future therapist, I will be expected not only to learn about various identities and how they may present in therapy, but that I will be expected to become an advocate for traditionally marginalized populations and for quality, equitable access to mental health care for all individuals, couples, and family constellations, regardless of their presentation in therapy.

Student Signature*

If you have questions about any of these items please discuss them with your current professor or request to meet with Dr. Patricia Postanowicz, MAMFT Foundations Program Director (MFSDepartment@nu.edu).

Date:*

Date