File a Complaint

Please fill out the following form using the CAPS LOCK feature on your keyboard.

Person Registering Complaint

Anonymous complaints will not be accepted.

First Name

Last Name

Complainant Address

Address Line 1

Address Line 2

City

State

Zip Code Format: 99999, numbers only

Person Registering Complaint Contact Information

Email Format: sample@domain.com

Phone Number Format: 111-111-1111

Relationship to Accused

Are you a licensee?

Yes No

Is this complaint being filed on behalf of any agency or employer?

Yes No

If yes, explain below. This entry is invalid.

Person Complaint is Being Registered Against

First Name

Last Name

AccusedAddress

Address Line 1

Address Line 2

City

State

Zip Code Format: 99999, numbers only

Phone Number Format: 111-111-1111

Is the Speech-Language Pathologist or Audiologist licensed by this Board?

Yes No Unknown

License Number (if known)

Description of Wrongdoing

Include specific details such as names of people involved, dates, location, particulars about the alleged violation(s), and any other pertinent facts.

Complaint Type

Work Place Setting

Facts of Alleged Wrongdoing Please be as specific as possible and provide names, dates, times, locations, etc.

If you have any additional documentation regarding this complaint that you would like to provide to the Board, please mail it to the LBESPA office.

Signature

ComplaintDate Format: mm/dd/yyyy

By typing your name in the signature field, you are signing this agreement electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this agreement.

Confirm Finalization

The information you are about to submit cannot be edited after it has been submitted. Please review all fields before finalizing your submission.

Yes, I understand.