Consumer Complaint Form – Breining Institute

Complaint form Instructions *

Complaint against a credentialed professional

You should file a complaint about a professional who has been certified by Breining Institute if you believe that the professional acted improperly, but not just because there is some disagreement between you, or you believe they did a poor job.
If you believe that a Breining Institute-credentialed individual breached their respective Code of Ethics or conducted themself in an unethical manner, you must file your complaint using this online form.
When you make your complaint, you should supply photocopies of any documents that relate to the asserted problem.
A complaint against a certified individual is taken very seriously, and the complainant must certify – under penalty of perjury and potential civil and criminal liability – that the statements made in the complaint are true.
The complainant will be required to supply a copy of government-issued identification, such as drivers license or passport.
Anonymous and/or undocumented complaints will not be recognized.
A copy of this complaint will be provided to the credentialed professional, which will require a detailed response to the allegations set forth in this complaint.

Please complete this online form carefully and completely

In order to process your complaint in a timely manner, we will appreciate you providing all of the information requested.
Please be prepared to upload a copy of a government-issued identification (ID) card of the person who is submitting this complaint.
To submit supporting documentation, you may do so by uploading it using this online form, or you may send it to us separately by email, using the following email address: college@breining.edu

Credentialed Professional *

Person against whom the complaint is being made

Please type information clearly. This information is required in order to commence an investigation.

Full Name: *

Address: *

City: *

State / Province: *

ZIP Code or Country Code:

Complainant Information *

Person Registering Complaint

PLEASE NOTE: The complainant will certify, under penalty of perjury, that the statements made in this complaint are true and correct; and, that if any of the provided statements are willfully false, the complainant understands that they may be subject to criminal and/or civil punishment.

Full Name: *

Address: *

City: *

State / Province: *

ZIP Code or Country Code: *

Country:

Country (if not the United States):

Email Address: *

Confirm Email Address: *

Primary Phone Number *

Secondary Phone Number

Government-issued ID Card Upload

Upload a copy of an identification card which includes your photo, in PDF or JPG format, such as a drivers license or passport or similar ID card that is issued by a government agency. Anonymous and/or undocumented complaints will not be recognized. If you are unable to upload a copy of your ID card here, please send it to us by email at college@breining.edu

Complaint Specifics *

Complaint specifics

If complainant is NOT the client:

If the person affected by the conduct of the professional is someone other than the person submitting this complaint, provide the FULL NAME and Date of Birth of the client, as well as the relationship between the client and the person filing the complaint, here.

Factual statement *

Please describe the facts of your complaint as completely as possible. Include witness names and contact information (address, telephone, e-mail) who can support your factual statement. Provide your complaint information and include as many specific details as possible (who, what, when, where, why). Include the date(s) of treatment and specific examples of the problem.

Resolution efforts *

Please describe any action taken to resolve this matter prior to contacting Breining Institute.

Supporting Documentation Upload

You may upload one PDF document here, which must be no larger than 5 MB. If you are unable to upload the document, please send it to us by email.

Complaint Submission *

The undersigned complainant certifies and understands the following:

The person submitting this complaint certifies and understands the following::

The person submitting this complaint certifies, under penalty of perjury, that the stated charges within this complaint are true and correct.
If any of the submitted statements are willfully false, the complainant understands that they may be subject to criminal and/or civil punishment.
This complaint must be accompanied by legible copies (not originals) of any complaint-related contracts, bills, receipts, cancelled checks, correspondence or any other documents that will support this complaint.
The undersigned waives any requirements of confidentiality, and authorizes disclosure of information, as Breining Institute deems necessary to investigate or pursue this complaint.
The undersigned will testify before an administrative board or in a court of law if requested to do so.
The undersigned may be contacted by Breining Institute for additional information relating to this complaint.
A copy of this complaint will be provided to the credentialed professional, which will require a detailed response to the allegations set forth in this complaint.
Until the complaint is fully investigated and resolved, Breining Institute is not permitted to disclose information regarding the investigation.

Attestation

By submitting this form, I attest that the information I have provided within this form is true and authentic.

Signature *

Please carefully use this space to sign your name.

Reset Signature

Signature is required.

Are you ready to submit this complaint?

If you are ready to submit your complaint, select the “Submit” button on the bottom of this page.

Please only select the “Submit” button one time.

Once it is successfully submitted, you will see a message on the screen that the complaint was “successfully submitted.”

If you have uploaded documents, it may take additional time for the complaint to be submitted.

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