Complaint Form - North Carolina Marriage And Family Therapy Licensure Board Page 4
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4Required Releases:
1) I hereby give the person against whom I am making the complaint permission to give the
Board or its agents all records of our interactions and to answer all questions the Board or
its agents may ask concerning these interactions. Yes
No
2) I hereby give the persons listed as potential witnesses permission to give the Board or its
agents any information or knowledge they may have of this situation. Yes
No
3) I hereby give the Board or its agents permission to release in part or in its entirety my
complaint form to the person against whom I am making the complaint, and to other
persons who may be contacted for information pertinent to the complaint. Yes
No
4) I agree to appear before the Board in a hearing if necessary. Yes
No
5) I understand that information may be subject to the public record statutes of North
Carolina. However, I request that the Board withhold from public disclosure my identity
and delete any identifying information concerning the treatment or delivery of MFT
services to me. Yes
No
Not Applicable (not a client or patient)
Signature
Date
Return Form via
Mail: NC MFT Licensure Board, PO Box 5549, Cary, NC 27512
E-Mail:
Fax: 919-336-5156
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