Complaint/inquiry Form - North Carolina Psychology Board Page 2
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26. If available, provide the names and addresses of other persons who could provide information or would be
potential witnesses, and state their relationship to the matter.
Name ___________________________________
Name ____________________________________
Address __________________________________
Address __________________________________
City,St,Zip ________________________________
City,St,Zip ________________________________
Telephone: (___)______________
Telephone: (___)______________
Relationship to Matter:___________________
Relationship to Matter:___________________
_________________________________________
_________________________________________
Name ____________________________________
Name ____________________________________
Address __________________________________
Address __________________________________
City,St,Zip ________________________________
City, St, Zip _______________________________
Telephone: (___)______________
Telephone: (___)______________
Relationship to Matter __________________
Relationship to Matter __________________
________________________________________
________________________________________
7. Required Releases:
A. I hereby give the person against whom I am making the complaint, permission to give the Board or its
employees or agents all records of our interactions and to answer all questions the Board or its
employees or agents may ask concerning those interactions.
B. I hereby give the persons listed under Item #6 on this form, or on an attached sheet, permission to
answer all questions the Board or its employees or agents may ask regarding their knowledge of this
matter.
C. I hereby give the Board or its employees or agents, permission to quote in part or entirety my complaint
letter(s) and this checklist to the person against whom I am making the complaint, and to other persons
who may be contacted for information pertinent to the complaint.
Date: _________________
Signature: _____________________________________
8. I agree to appear before the Board in a formal or informal hearing, as may be necessary.
Yes
No (attach explanation)
Date: _________________
Signature: _____________________________________
9. I understand that information received 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 psychological services to me.
Yes
No
Not Applicable (i.e., not a client or patient)
Date: _________________
Signature: _____________________________________
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