Complaint/inquiry Form - North Carolina Psychology Board

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NORTH CAROLINA PSYCHOLOGY BOARD
895 State Farm Road, Suite 101
Boone, North Carolina 28607
Telephone: (828) 262-2258
COMPLAINT/INQUIRY FORM
Complete and mail this form to the above address.
(Faxed or electronic submissions are not accepted at this time.)
1. Person Making Complaint: _______________________________________________________________
Address: _____________________________________________________________________________
City, State, Zip Code: _________________________________________ Telephone: (___)___________
Email Address
2. Person Complained About: _______________________________________________________________
Address: _____________________________________________________________________________
City, State, Zip Code: _________________________________________ Telephone: (___)___________
Is this person licensed as a psychologist in North Carolina?
Yes
No
3. Give a specific and detailed description of the ethical and/or legal violation(s).
If familiar with the APA Ethics Code and/or the NC Psychology Practice Act, cite the Standard(s) and/or
statute(s) which you feel have been violated. (Attach additional sheets if necessary.)
4. Give the dates of violation(s). _________________________________________________________
5. Have you discussed this situation with the person about whom you are complaining?
Yes
No
Yes
No
Have you taken any other action?
(if yes, describe):

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