To submit the form, you can copy and paste the text from below into an email, and send it to email@example.com
IMHPJ ETHICS VIOLATION COMPLAINT LETTER
FOR ALLEGED VIOLATION OF THE IMHPJ CODE OF ETHICS
- Anonymous complaints are not accepted.
- An individual who is a current IMHPJ member must be named as Respondent.
- The complaint must be in writing using this form, and include any/all supporting documentation.
- Any additional information after submission should be added to this form and the form resubmitted.
- A copy of this complaint form and all attachments will be provided to the individual against whom this complaint is filed.
- A signed copy of this form must be submitted for IMHPJ to proceed with investigation.
For more information about the complaints process please refer to IMHPJ Code of Ethics 4. Resolving ethical Issues
COMPLAINANT: (Individual filing the complaint)
RESPONDENT: (Individual against whom the complaint is directed)
- E-Mail (if known):
- Link to IMHPJ member profile:
ABOUT YOUR COMPLAINT:
Please identify which section(s) of the IMHPJ Code of Ethics, you believe have been violated from below and explain the factual basis of your complaint. Write N/A for any that are not applicable.
Please include any discussions or conversations with the Respondent, timeline of events, places, any efforts to resolve your concerns, and the results thereof. Please also include any supporting documents.
- 2.1 Client-Centeredness
- 2.2 Treatment Relationship
- 2.3 Privacy and Confidentiality
- 2.4 Protection of Client’s Rights
- 2.5 Professional Competence
- 2.6 Conflicts between Ethics and Organizational Demands
- 2.7 General Issues
- 2.8 Others (please specify from the Code of Ethics)
COMPLAINANT CONFIDENTIALITY, RELEASE OF INFORMATION, AFFIRMATION, AND SIGNATURE:
Please read the following carefully before signing.
ETHICS COMPLAINT CONFIDENTIALITY AND RELEASE OF INFORMATION
I understand that, by signing and submitting this form for the purpose of investigation and any discipline,
I am giving the IMHPJ Ethics Committee permission to share all of the information contained in my complaint, and any additional information that I submit, with only the following:
- *the IMHPJ ethics committee / panel investigating the complaint
- *the respondent against whom the complaint is being made
- *legal counsel (where required)
- *any other experts involved in handling the complaint
- *members of the Appeal Panel, in the event of an appeal
My information shall not be revealed in any manner to anyone except those members charged with the responsibility of investigating the complaint mentioned above, and to the Respondent for their response as part of the investigation.
- I have read the IMHPJ Code of Ethics instructions for 4. Resolving Ethical Issues and understand that the investigation and resolution process may take several months.
- I have read and cited the section(s) of IMHPJ’s Code of Ethics that have allegedly been violated.
- I have enclosed a written summary of the facts on which this complaint is based.
- I have enclosed supporting documentation (if any) that corroborates and supports the allegations in the complaint and redacted confidential information, if any.
- I affirm that the statements and information in this complaint are correct, complete, and truthful to the best of my knowledge.
- By signing and submitting this form, I acknowledge that I have granted my permission to initiate an inquiry against the respondent based on the allegations outlined in this complaint.
- I waive my right to subpoena IMHPJ or its agents, for the purposes of private civil litigation, any documents or information concerning the complaint.
Signature OR typed name of Complainant