Licensing Complaint for Individual Form

Licensed Individual Complaint

Individual Involved in Complaint

First Name

Last Name

License Number

Profession

License Type

Did you take legal action or make a police report?

Yes

Tell Us About Yourself

First Name

Last Name

Address

City

State

Zip Code

Phone Number

Area of Compliant

Please select which pertains to your complaint. You can select all that apply.

Action by another board agency

Advertising

Quality of care

Unprofessional conduct

Fraud

Other

Detailed Complaint Description

Please provide a detailed explanation of your complaint. Include names, addresses, dates, etc., regarding all parties involved.

Attachment(s)

Unlimited number of files can be uploaded to this field.
24 MB limit.
Allowed types: jpg, jpeg, png, tif, tiff, pdf.
24 MB limit per form.

Your complaint will be given serious consideration by the board and further investigative action may be taken, if appropriate. You may be contacted by the board investigator. A referral of a complaint for further investigation does not necessarily mean that a licensing violation has occurred. Investigations are completed as soon as possible, depending upon the nature and circumstances of the complaint. Investigative files are considered confidential (pursuant to O.C.G.A. 43-1-19(h) (2)), with the exception of Music Therapy and Lactation Consultants, for any purpose other than a hearing before the board; however, the board is authorized to release such records to another enforcement agency or lawful licensing authority. Music Therapy and Lactation Consultant complaints are not confidential and may be made available to the public.

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