Professional Disclosure Statement Form - City Of Lansing

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If you choose to use this Professional Disclosure Statement form, please complete the form, print it out, and submit it to
the Michigan Board of Counseling PO Box 30670 Lansing MI 48909.
PROFESSIONAL DISCLOSURE STATEMENT
PROFESSIONAL COUNSELOR
Full Name
Business Street Address
City, State, Zip Code
Telephone Number
DESCRIPTION OF EDUCATION AND EXPERIENCE
Click here to enter text.
DESCRIPTION OF YOUR PRACTICE
Click here to enter text.
FEE
Click here to enter text.
In the event that you would like to file a complaint regarding services, send written complaints to the following location:
Michigan Department of Licensing and Regulatory Affairs
Enforcement Division
Allegations Section
PO Box 30670
Lansing MI 48909
(517) 373-9196

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