Mississippi State Board of Examiners for Licensed Professional Counselors
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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 it these boxes are not checked.


Complainant (Your) Name:
       
Your Street Address/Apt No.:
           City / State / Zip: / /
            County:


Your Mailing Address: (if different)
           City / State / Zip: / /
Your Telephone Number:  (Home)


Name of person against whom you are filing a complaint:
       
Address of person against whom you are filing a complaint:
               Address:
               City / State / Zip: / /
Telephone number of person:  (Home)


Nature of Complaint:

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:
 
Maiden Name Sex Date of Birth Social Security Number