Fillable Official Complaint Form printable pdf download

Official Complaint Form

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Office Use Only: Date Rec’d ____________ Complaint No. ________________

MISSISSIPPI STATE BOARD OF EXAMINERS for SOCIAL WORKERS

and MARRIAGE AND FAMILY THERAPISTS

OFFICIAL COMPLAINT FORM

(Please type or print in black ink. No corrections, white-outs or write-overs will be accepted.)

I, the undersigned, wish to file an official complaint against _____________________________________, a social worker _____ or

marriage and family therapists _____ licensed by this Board. License Number, if known,_____________,

Home address: ______________________________________________________________________________________________

Employer’s Telephone No. (_______) ________________________ Home Phone: (_____) _________________________

Name and address of person (s) against whom alleged offense was perpetrated:

___________________________________________________________________________________________________

___________________________________________________________________________________________________________

Complainant’s relationship to person against whom complaint is being filed (e.g. supervisor, co-worker, patient,etc)

___________________________________________________________________________________________________________

What is your complaint? Please be specific. (

In your own words tell who, when, where, and how about the complaint. Tell why you feel harmed.

Continue on back of page if needed

How does this action or incident(s) violate the Social Worker’s or Marriage and Family Therapists’ Code of Ethics or Standard of

Conduct?

What are the approximate date or dates of this alleged offense?

Where did the

alleged offense occur? City

State

County

Name of Complainant:

Address:

PH :(_____)

I, the undersigned, do solemnly swear or affirm that I am the above complainant. Subscribed and sworn to before me on this ________ day of

All the above and/or attached statements are true to the best of my knowledge

__________________________, 20_______.

and belief. I am willing to testify to these matters before this Board or court

My commission expires ____________________________

of law if called to do so.

Notary Public

Complaint’s Signature

Date

Affix seal here

Complete , notarize and mail this form to: MSBOESWMFT, P.O. Box 4508, Jackson, MS 39296-4508

Official Complaint Form

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