Complaint Form - North Carolina Marriage And Family Therapy Licensure Board Page 2
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4NORTH CAROLINA MARRIAGE AND FAMILY THERAPY LICENSURE BOARD
Post Office Box 5549, Cary, NC 27512
Phone: (919) 469-8081
Fax: (919) 336-5156
Email: Web:
COMPLAINT FORM
Assigned Complaint # __________________
(MFT Licensure Board Use Only)
Complainant
Therapist Name
(person making complaint)
(person complained about)
Name
Address
City
State
Zip
Phone
Email
Website
of
therapist
Is this person licensed as a Marriage and Family Therapist in North Carolina?
Yes
No
Unknown
MFT License Number if known ___________
Date(s) of alleged violation(s)
Have you discussed this situation with the therapist?
Yes
No
I am or have been a client of the person about whom I am making a complaint.
Yes
No
Have you taken any other action? Yes
No
If yes, describe.
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