Complaint Form - North Carolina Marriage And Family Therapy Licensure Board Page 3
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4Assigned Complaint # __________________
(MFT Licensure Board Use Only)
List names, addresses, phone numbers and relationship to situation of persons who could
give information or may be potential witnesses.
Name
Name
Address
Address
City, State, Zip
City, State, Zip
Phone
Phone
Email
Email
Relationship to Matter
Relationship to Matter
Name
Name
Address
Address
City, State, Zip
City, State, Zip
Phone
Phone
Email
Email
Relationship to Matter
Relationship to Matter
Type or print (black ink only) a detailed description of the ethical and/or legal violations
here – attach additional pages if needed. The Code of Ethics may be reviewed via a Quick
Link at
– public resources section.
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