LOUISIANA LICENSED PROFESSIONAL COUNSELORS

BOARD OF EXAMINERS

Use this form for complaints against (1) Licensed Professional Counselors and Interns; (2) Licensed Marriage and Family Therapists and Interns; and (3) unlicensed persons who practice counseling. Please type or print. If you are uncertain about any of the information, enter ‘unknown.’ Sign and return the completed form to the LPC Board: 8631 Summa Avenue, Baton Rouge, LA 70809, ATTN: Complaint Committee. Mark envelope CONFIDENTIAL.

 

If you need additional information, contact the LPC Board:

Phone: (225) 765-2515

E-mail: lpcboard@eatel.net

Web site: www.lpcboard.org

COMPLAINANT (Person Reporting)

  • Name: ______________________________________________________
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  • Address: ______________________________________________________

    • Phone: Day ( ) _____________ Evening ( ) _____________

    E-mail: ______________________________________________________

    Your relationship to counselor:

    ______ Client*

    ______ Friend or family member of person counseled*

    ______ Co- professional

    ______ Other (explain) _________________________________________

    * If complaint involves a counseling relationship, complete the following:

    Date counseling relationship began: ____________________

    Date problem first occurred: ____________________

    Date counseling relationship terminated: ____________________

     

    PROFESSIONAL COUNSELOR/MARRIAGE & FAMILY THERAPIST

  • Name: ______________________________________________________
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  • Address: ______________________________________________________
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  • Phone: Day ( ) ______________ Evening ( ) ______________

    • E-mail: ___________________

    Is the Professional Counselor/ Marriage & Family Therapist licensed by this Board?

    _____ Yes License # ____________

    _____ No

    _____ Unknown

    Counselor’s employer or place of business:

  • Name: ____________________________________________________
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  • Address: ____________________________________________________

    • ____________________________________________________

  • Phone : ( ) ___________________ E-mail: ________________
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                    ALLEGED VIOLATION(S)

  • Explain clearly the reason for filing the complaint. Use additional sheets, if necessary. If you have any documents that will support the complaint, please attach copies. (Examples: canceled checks, judgments, court orders, business cards, advertisements, photographs, correspondence, etc.)
  • ____________________________________________________________________
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  • ____________________________________________________________________
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  • ____________________________________________________________________
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  • ____________________________________________________________________
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  • ____________________________________________________________________
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  • ____________________________________________________________________
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  • ____________________________________________________________________

    • ‘ continued on attached pages

    If the Board decides to hold a hearing, you must be willing to testify in front of a formal hearing panel. The hearings are usually held in Baton Rouge. You may be subject to cross-examination at the hearing by attorneys, and relevant documents can be subpoenaed by the Board.

    I have read and answered all the above statements to the best of my knowledge.

     

    Signature ______________________________________ Date_____________

     

    For office use only

    Date rec’d

    Date accepted

    File #

    rev. 2/26/04