DISCLAIMER: By sharing this email template with information, Deaf Vee Journal‘s intention to empower Deaf, DeafBlind, DeafDisabled, hard of hearing, and late-deafened community members in knowing their own rights for their preemptive safety and having access to the proper venues for reporting in the event of provider misconduct. We are absolved of any responsibility or liability related to this post, and we ask you not to interpret this as legal advice.


Subject: Complaint Against [Name at Program/Office]

To Whom It May Concern:

My name is _____________ and I [was/am] a client from [date] to [date] at [name of office or program], located at [insert address]. I received services from [name of psychiatrist, dentist, counselor, doctor, optometrist, surgeon], and I want to file a complaint. The license/certification number for [insert provider’s name] is _______________.

[Describe what happened, when, who, where, how]. I can be reached at [phone number] or [e-mail address].

Thank you for your time,

[Your Name]

In the state of California, complaints often require you to include the employee’s license or certification number, and you need to make sure the license or certification number is accurate. Some of the agencies below do allow you to make complaints anonymously, and you can report either suspected or actual incidents of misconduct. If you do not have any complaint, you still have the right to ask your provider for their license or certification number and verify it online on your own anytime–even before you become their client.

E-mail templates with information on state boards for license/certification verification can be made available for other states. If you need assistance in completing your complaint, contact your local Deaf advocate.