STATE BOARD OF BEHAVIORAL HEALTH LICENSURE
REQUEST FOR INQUIRY
(Type or print legibly)
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:
click to sign
signature
click to edit