Mississippi State Board of Examiners for Licensed Professional Counselors Today is: 4 Steps To Complete Complaint MISSISSIPPI BOARD OF EXAMINERS FOR LICENSED PROFESSIONAL COUNSELORS COMPLAINT FORM This is the official form for filing a complaint with the Mississippi State Board of Examiners for Licensed Professional Counselors. The nature of the complaint should be clearly and thoroughly stated. The check boxes at the bottom of the form are your electronic signature. The form will not be processed if these boxes are not checked. Complainant (Your) Name: First Middle Last Your Street Address/Apt No.: City / State / Zip: / Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Washington, DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming / County: Email: Your Mailing Address: (if different) City / State / Zip: / Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Washington, DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming / Your Telephone Number: (Work) (Home) Name of person against whom you are filing a complaint: First Middle Last Address of person against whom you are filing a complaint: Address: City / State / Zip: / Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Washington, DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming / Telephone number of person: (Work) (Home) Nature of Complaint:(include specific details and indicate all alleged ACA code of ethics violations)Please provide as many details as possible to assist with any type of investigative process.If you do not provide adequate information, you run the risk of not having complaint processed/reviewed/assessed. Supporting information may be mailed or uploaded. Upload instructions will be provided after you finish this form. Witnesses information will be entered on the next screen. Complainant identifying data: FemaleMale Maiden Name Gender Enter Social Security or Driver's License Number: Check one: SSN Dr Lic # Enter Number: If Driver's Lic Select State: Select Alabama Alaska Arkansas Arizona California Colorado Connecticut Washington, DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming