Malaysian Society of Clinical Hypnosis Complaint Form

Malaysian Society of Clinical Hypnosis Complaint Form
Your Details

Note: Anonymous complaints may limit our ability to act on follow-ups and verifications.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Client/PatientMSCH Member (Therapist)Other
Therapist Details

The individual you are making the complaint about
Full Name of Therapist*
Therapy Platform*
Location (State)*
e.g. Selangor, Kedah, Kuala Lumpur, etc.
Location (City)*
e.g. Petaling Jaya, Kulim, Putrajaya, etc.
Nature of the Complaint
Inappropriate use of hypnosisConsent issuesCompetence or qualificationsMisrepresentation of MSCH membershipConflict with another practitionerUnprofessional behaviorBreach of ethical conductOther
Details of the Incident

Please describe in detail what occurred
Date of incident*

MonthDayYear
Please describe the situation in your own words (include as many specific details as possible):*
Supporting Evidence

Attach relevant documents, emails, messages, session notes, etc.
Yes (Please attach)No
Upload supporting documents here

Supporting format: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
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Have You Taken Any Prior Action?
Have you discussed this issue with the therapist involved? If yes, please provide a summary of the conversation.*
Have you reported this issue to another body (e.g., licensing board, clinic, legal authority)? If yes, to whom and what was the outcome?*
Desired Outcome
MediationRemoval of memberFormal warningInvestigation and disciplinary actionReferral to legal authorities
If your preferred resolution is not listed above please specify here:
Declaration
I confirm that the information I have provided is true to the best of my knowledge and that I am submitting this complaint in good faith. I understand that the MSCH may need to contact me for further information and may share necessary details of this complaint with the therapist in question as part of a fair investigation.
Date*

MonthDayYear
Signature*

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Malaysian Society of Clinical Hypnosis Complaint Form

Your Details

Therapist Details

Nature of the Complaint

Details of the Incident

Supporting Evidence

Have You Taken Any Prior Action?

Desired Outcome

Declaration