This version supersedes all previous versions Complaint/Inquiry Form
9. Required Releases:
For electronic complaint submissions (ONLY):
I understand that typing my first and last name on the signature lines below will
be considered to be my electronic signature that has the same legal effect and
can be enforced in the same way as my written signature.
A. I hereby give the person against whom I am making the complaint, permis-
sion to give the Board, its employees, or agents all records of our interactions
and to answer all questions the Board, its employees, or agents may ask re-
garding these interactions.
B. I hereby give the persons listed under item #7 on this from, or on an attached
sheet, permission to answer all questions the Board, its employees, or agents
may ask regarding their knowledge of this matter.
C. I hereby give the Board, its employees, or agents, permission to quote in part
or entirely my complaint letter(s) and this form to the person against whom I
am making the complaint, and to other persons who may be contacted for in-
formation pertinent to the complaint.
Signature: Date:
10. I agree to appear before the Board in a formal or informal hearing as may be re-
quired: ❑yes ❑no (If no, attach explanation)
Signature: Date:
11. I understand that information received may be subject to 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
counseling services to me.
❑yes ❑no ❑I am not/have not been a client of the LCMHC
Signature: Date:
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signature
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click to sign
signature
click to edit
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click to sign
signature
click to edit
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