Ethics Complaint Form

This form is used to file a formal ethics complaint against a Michigan Certification Board for Addiction Professionals (MCBAP) professional and those in a development plan.

Prior to completing the ethics complaint, please:

Confirm that the individual has a MCBAP credential: https://mcbap.certemy.com/public-registry/3b1487e7-9ca6-4b71-b014-1f649cfe0e24
Review the applicable Code of Ethics:
- CADC, CAADC and CCJP: https://mcbap.com/counselors-criminal-justice-code-of-ethics/
- CPS and CPC: https://mcbap.com/prevention-code-of-ethics/
- CCS: https://mcbap.com/supervisor-code-of-ethics/
- CPRM: https://mcbap.com/peer-recovery-code-of-ethics/
Review the Guide for Ethical Standards Violation Complaints.

Your information (complainant)

Complainant Name(Required)

First Last

Complainant Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Complainant Phone(Required)

Complainant Email(Required)

Complaint filed against (respondent)

Respondent Name(Required)

First Last

MCBAP credential(s) held(Required)

CAADC

CADC

CCS

CPS

CPC

CPRM

CCJP - M

Respondent Employer

Respondent Address

Street Address City State / Province / Region ZIP / Postal Code

Respondent Phone

Respondent Email

Other Persons

List other persons who might have information pertinent to your complaint.

Person 1

Person 1 Name

First Last

Person 1 Address

Street Address City State / Province / Region ZIP / Postal Code

Person 1 Email

Person 1 Phone

Person 2

Person 2 Name

First Last

Person 2 Address

Street Address City State / Province / Region ZIP / Postal Code

Person 2 Email

Person 2 Phone

Basis

Describe the conduct that is the basis of your complaint. Please include the dates the conduct occurred and any other facts pertinent to the investigation of your complaint. Please provide as much concise detail as possible. Include applicable attachments.

Basis of complaint(Required)

Attachment(s)/File(s)

Drop files here or

Max. file size: 256 MB, Max. files: 10.

Attach any files (e.g. photos, documents) that support your complaint.

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Phone

This field is for validation purposes and should be left unchanged.