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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 if these boxes are not checked.


Complainant (Your) Name:
       
Your Address:
           City / State / Zip: / /
            County:
Email:
Your Telephone Number:  (Home)


The person you are filing a complaint against is:
      LPC      P-LPC      Other
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)


Enter your Social Security or Driver's License Number:
Check one:           
If Driver's Lic Select State:
Relationship to Alleged:
Date of Alleged Violation:


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.
You may or may not be contacted by the investigator for additional information regarding the complaint. Please note that the incomplete or anonymous complaints may hinder the investigator's ability to conduct a thorough investigation and may limit the action the Board is able to take.

Supporting information should be uploaded.
Upload instructions will be provided after you finish this form.
If unable to upload, documentation may be mailed to the Board office.

I will be mailing information to the Board office.
    No       Yes