Louisiana LPC Board Complaint Form

This complaint form is used to file complaint(s) against (1) Licensed Professional Counselors (LPCs), (2) Provisional Licensed Professional Counselors (PLPCs), (3) Licensed Marriage and Family Therapists (LMFTs), (4) Provisional Licensed Marriage and Family Therapists (PLMFTs), (5) unlicensed persons who are practicing mental health counseling or marriage and family therapy, and (6) unlicensed persons advertising themselves as a LPC, LMFT, PLPC, or PLMFT. Please note that if you choose to submit a third party complaint or an anonymous complaint, the Disciplinary Affairs Committee of the Board may be limited in the course of action it can take.

Please complete this form to the best of your ability and provide all relevant information. Please mail or email any additional documentation to lpcboard@lpcboard.org.

Required fields are denoted by this symbol:

Complainant Information:

I wish to remain anonymous

First Name

Last Name

Phone Number Type

Cell

Home

Work

Phone

Email Address

Business Name (if applicable)

Mailing Address Line 1

Mailing Address Line 2

City

State

ZIP Pattern: 12345 You must enter a valid Zipcode.

Relationship to Alleged Violator

Date Professional Relationship Began:

Date Professional Relationship Ended:

Date When First Problem Occurred:

Report Details:

Please be advised that more detailed information and documentation will allow for a more thorough and timely investigation.

All information requested in the section below is in reference to the Alleged Violator.

Alleged Violator's First Name

Alleged Violator's Last Name

Business Name (if applicable)

Phone Number Type

Cell

Home

Work

Phone

Sending additional information via mail or email:

Yes

Mailing Address line 1

Mailing Address line 2

City

State

ZIP Pattern: 12345 You must enter a valid Zipcode.

Is the individual licensed by the LPC Board?

Yes

Unknown

If the alleged violator is licensed by another professional board, please consider filing a separate complaint with the appropriate licensing board.

Please clearly explain your reasoning for filing this complaint.

Please include additional documentation that will support the complaint (e.g. cancelled checks, judgments, court orders, advertisements, correspondence). Please be as specific as possible.

If possible, please provide a list of contacts (names, phone numbers, addresses, and nature of involvement) of all those involved, including witnesses or those who may have knowledge of the issue of concern.

Have you previously contacted the alleged violator regarding your concerns?

If yes, please include the date of contact and his/her response to your concerns.

Has your complaint been reported to any other agency, court, or other entity?

If so, when? Please provide the appropriate information (which agency, court, and contact information).

I understand by filing this complaint, I do authorize the Louisiana Professional Councelors Board of Examiners to investigate and resolve this matter in accordance with the Board's rules and regulations.

By typing your name in the signature field, you are signing this agreement electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this agreenemt.