Fill - Free fillable KENTUCKY BOARD OF LICENSED PROFESSIONAL COUNSELORS Complaint Form (Commonwealth of Kentucky) PDF form

Complaint No:

Date Received:

KENTUCKY BOARD OF LICENSED PROFESSIONAL COUNSELORS

Complaint Form

Your Name:

Address:

City:

State:

Zip Code:

Home Telephone:

( ) -

Work Telephone:

( ) -

Name of KY Professional Counselor your complaint is against:

Address:

City:

State:

Zip Code:

Have you filed this complaint with other agencies? Yes No. If yes, list the agencies:

Brief Summary of Complaint

Please attach copies of any supporting documentation pertaining to the complaint. (A copy of your complaint will be sent to

the counselor asking for a response. You complaint and response will be presented to the board at the next scheduled

meeting.)

By signing this complaint form, I hereby certify that the information is complete and true to the best of my knowledge.

Signature: ____________________________________ Date: ______________________________

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Send to:

KENTUCKY BOARD OF LICENSED PROFESSIONAL COUNSELORS

Phone: (502)564-3296

PO BOX 1360

Fax: (502)564-4818

FRANKFORT, KY 40601

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KENTUCKY BOARD OF LICENSED PROFESSIONAL COUNSELORS Complaint Form (Commonwealth of Kentucky)

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