ABFFD Formal Consumer Complaint

ABFFD Formal Consumer Complaint
Full Name of Person Filing Complaint*

First NameLast Name
Relationship to Board-Certified Specialist*
(e.g. Client or Parent/Guardian, if Client is a minor)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Preferred Means of Contact*
Name of Board-Certified Specialist*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Work*
Date Seen for Therapy*

MonthDayYear
Date
Please inform the ABFFD if you have or plan to submit this complaint to your state or national licensing boards or are taking legal action.*
Describe the complaint and relevant background and situation:*
Attachments

Browse Files
Please attach any relevant documents to your complaints or additional correspondence. Cancelof
Attestation:

I attest that I am the client or parent/guardian who received services from the Board-Certified Specialist (BCS-F) named in this complaint. I agree to allowing the information in this complaint to be shared with the executive board of the ABFFD and the clinician named in this complaint. (Note, your name will be shared, however, your contact information will not). I agree that the executive board of the ABFFD may contact me for further information regarding this complaint.
First Name Last Name Date
Should be Empty: