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STATE BOARD OF BEHAVIORAL HEALTH LICENSURE

REQUEST FOR INQUIRY

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I, the undersigned, file a formal request for inquiry with the State Board of Behavioral Health Licensure against:

Name of Licensee/Candidate/Applicant:

Name of person making inquiry:

Street Address:

City, State and Zip Code:

Telephone Number:

Is the individual making the inquiry a current or former client of the license/candidate/applicant?

 Yes  Current  Former Age at the time counseling services were rendered:

 No

If no, what is relation to the individual to whom counseling services were rendered?

Name and Age(s) of the individual(s) to whom counseling services were rendered?

_________________________________________________________________________________________________

If this complaint relates to and/or involves a court proceeding, please complete the following:

Style of case: Case #/Forum:

Provide the complaint details on the reverse side of this form.

For Office Use Only:

Check appropriate license(s) or application:

 Professional Counselor  Marital and Family Therapist  Behavioral Practitioner  Unlicensed

License Number(s)

Street Address:

City, State and Zip Code:

Telephone Number:

Licensed Behavioral Practitioners

Licensed Marital and Family Therapists

Licensed Professional Counselors

State Board of Behavioral Health Licensure

3815 N. Santa Fe, Ste. 110

Oklahoma City, OK 73118

Telephone: (405) 522-3696

Fax: (405) 522-3691

www.ok.gov/behavioralhealth

Describe your complaint in detail including the nature, frequency, duration, circumstances, and date(s) of the

alleged violation. If you need additional space, please make copies of this page. If your complaint pertains to court

testimony, please include a copy of the court transcript documenting the testimony in question.

___________________________________________________________________________________________________

________________

___________________________________________________________________________________________________

The information given above and attached is true and accurate to the best of my knowledge. I realize the serious

nature of filing such a complaint and recognize that the State Board of Behavioral Health Licensure may not be able to

take action without my cooperation in providing additional information if requested.

Signature of complainant: Date:

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STATE BOARD OF BEHAVIORAL HEALTH LICENSURE REQUEST FOR (Oklahoma)

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