{"id":29441,"date":"2023-09-30T09:49:51","date_gmt":"2023-09-30T16:49:51","guid":{"rendered":"https:\/\/www.breining.edu\/?page_id=29441"},"modified":"2023-09-30T10:10:10","modified_gmt":"2023-09-30T17:10:10","slug":"consumer-complaint-form","status":"publish","type":"page","link":"https:\/\/www.breining.edu\/index.php\/professional-certification\/consumer-complaint-form\/","title":{"rendered":"Consumer Complaint Form"},"content":{"rendered":"<form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-103\" class=\"vfbp-form\"><div style=\"display:none;\"><label for=\"vfbp-EMAIL-AN8fuQyoDLXem\">If you are human, leave this field blank.<\/label><input size=\"25\" autocomplete=\"off\" type=\"text\" name=\"vfbp-EMAIL-AN8fuQyoDLXem\" value=\"\" id=\"\"><\/div><input type=\"hidden\" name=\"_vfb-timestamp-103\" value=\"1777491775\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"103\" id=\"\"><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Complaint form Instructions <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField3198\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField3200\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3200\" class=\"vfb-control-label\"><\/label><div class=\"\"><h3><span style=\"color: #008000;\">Complaint against a credentialed professional<\/span><\/h3>\n<ul>\n<li>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.<\/li>\n<li>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.<\/li>\n<li>When you make your complaint, you should supply photocopies of any documents that relate to the asserted problem.<\/li>\n<li>A complaint against a certified individual is taken very seriously, and the complainant must certify &#8211; under penalty of perjury and potential civil and criminal liability &#8211; that the statements made in the complaint are true.<\/li>\n<li>The complainant will be required to supply a copy of government-issued identification, such as drivers license or passport.<\/li>\n<li>Anonymous and\/or undocumented complaints will not be recognized.<\/li>\n<li>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.<\/li>\n<\/ul>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField3199\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3199\" class=\"vfb-control-label\"><\/label><div class=\"\"><div class=\"page\" title=\"Page 1\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<h3><span style=\"color: #008000;\">Please complete this online form carefully and completely<\/span><\/h3>\n<div class=\"page\" title=\"Page 1\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<div class=\"page\" title=\"Page 1\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<div class=\"page\" title=\"Page 1\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<ul>\n<li>In order to process your complaint in a timely manner, we will appreciate you providing all of the information requested.<\/li>\n<li>Please be prepared to upload a copy of a government-issued identification (ID) card of the person who is submitting this complaint.<\/li>\n<li>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<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Credentialed Professional <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField3237\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Person against whom the complaint is being made<\/div><span class=\"vfb-help-block\">Please type information clearly. This information is required in order to commence an investigation.<\/span><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField3238\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3239\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3239\" class=\"vfb-control-label\">Full Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3239\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3239\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3240\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3240\" class=\"vfb-control-label\">Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3240\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3240\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3241\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3241\" class=\"vfb-control-label\">City: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3241\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3241\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3242\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3242\" class=\"vfb-control-label\">State \/ Province: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3242\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3242\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3243\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3243\" class=\"vfb-control-label\">ZIP Code or Country Code:<\/label><div><input id=\"vfb-field-3243\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-3243\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Complainant Information <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField3202\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Person Registering Complaint<\/div><span class=\"vfb-help-block\">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.<\/span><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField3203\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3204\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3204\" class=\"vfb-control-label\">Full Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3204\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3204\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3205\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3205\" class=\"vfb-control-label\">Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3205\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3205\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3206\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3206\" class=\"vfb-control-label\">City: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3206\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3206\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3207\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3207\" class=\"vfb-control-label\">State \/ Province: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3207\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3207\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3208\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3208\" class=\"vfb-control-label\">ZIP Code or Country Code: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3208\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3208\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-select\" id=\"vfbField3209\"><label for=\"vfb-field-3209\" class=\"vfb-control-label\">Country:<\/label><div><div class=\"vfb-form-group\"><select id=\"vfb-field-3209\" class=\"vfb-form-control\" placeholder=\"\" name=\"vfb-field-3209\"><option value=\"United States\">United States<\/option><option value=\"Other\">Other<\/option><\/select><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3210\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3210\" class=\"vfb-control-label\">Country (if not the United States):<\/label><div><input id=\"vfb-field-3210\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-3210\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField3211\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3211\" class=\"vfb-control-label\">Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3211\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-3211\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField3212\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3212\" class=\"vfb-control-label\">Confirm Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3212\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" data-vfb-equalto=\"#vfb-field-3211\" type=\"email\" name=\"vfb-field-3212\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-phone\" id=\"vfbField3213\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3213\" class=\"vfb-control-label\">Primary Phone Number <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3213\" class=\"vfb-form-control vfb-intl-phone\" placeholder=\"\" required=\"required\" type=\"tel\" name=\"vfb-field-3213\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3214\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3214\" class=\"vfb-control-label\">Secondary Phone Number<\/label><div><input id=\"vfb-field-3214\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-3214\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField3217\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3217\" class=\"vfb-control-label\">Government-issued ID Card Upload<\/label><div><span class=\"vfb-help-block\">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<\/span><input id=\"vfb-field-3217\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" data-max-file-size=\"5000\" data-max-file-count=\"1\" data-allowed-file-extensions=\"pdf,jpg,jpeg\" type=\"file\" name=\"vfb-field-3217\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Complaint Specifics <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField3219\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Complaint specifics<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField3220\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField3222\"><label for=\"vfb-field-3222\" class=\"vfb-control-label\">Relationship between complainant and the consumer or client \/ patient? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3222-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3222\" required=\"required\" type=\"checkbox\" name=\"vfb-field-3222[0]\" value=\"1\">Self<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3222-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3222\" type=\"checkbox\" name=\"vfb-field-3222[1]\" value=\"1\">Parent<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3222-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3222\" type=\"checkbox\" name=\"vfb-field-3222[2]\" value=\"1\">Spouse<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3222-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3222\" type=\"checkbox\" name=\"vfb-field-3222[3]\" value=\"1\">Brother \/ Sister<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3222-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3222\" type=\"checkbox\" name=\"vfb-field-3222[4]\" value=\"1\">Son \/ Daughter<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3222-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3222\" type=\"checkbox\" name=\"vfb-field-3222[5]\" value=\"1\">Legal Guardian<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3222-6\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3222\" type=\"checkbox\" name=\"vfb-field-3222[6]\" value=\"1\">Other<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3247\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3247\" class=\"vfb-control-label\">If complainant is NOT the client:<\/label><div><span class=\"vfb-help-block\">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. <\/span><input id=\"vfb-field-3247\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-3247\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField3244\"><label for=\"vfb-field-3244\" class=\"vfb-control-label\">What is the nature of the complaint? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3244-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3244\" required=\"required\" type=\"checkbox\" name=\"vfb-field-3244[0]\" value=\"1\">Administrative \/ Recordkeeping<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3244-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3244\" type=\"checkbox\" name=\"vfb-field-3244[1]\" value=\"1\">Advertising<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3244-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3244\" type=\"checkbox\" name=\"vfb-field-3244[2]\" value=\"1\">Fees \/ Billing Practices<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3244-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3244\" type=\"checkbox\" name=\"vfb-field-3244[3]\" value=\"1\">Fraud<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3244-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3244\" type=\"checkbox\" name=\"vfb-field-3244[4]\" value=\"1\">Incompetence<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3244-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3244\" type=\"checkbox\" name=\"vfb-field-3244[5]\" value=\"1\">Insurance Fraud<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3244-6\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3244\" type=\"checkbox\" name=\"vfb-field-3244[6]\" value=\"1\">Professional Misconduct<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3244-7\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3244\" type=\"checkbox\" name=\"vfb-field-3244[7]\" value=\"1\">Sexual Misconduct<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3244-8\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3244\" type=\"checkbox\" name=\"vfb-field-3244[8]\" value=\"1\">Substance Abuse<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3244-9\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3244\" type=\"checkbox\" name=\"vfb-field-3244[9]\" value=\"1\">Unlicensed Practice<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3244-10\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3244\" type=\"checkbox\" name=\"vfb-field-3244[10]\" value=\"1\">Other<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField3245\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3245\" class=\"vfb-control-label\">Factual statement <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">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.<\/span><textarea id=\"vfb-field-3245\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" data-vfb-maxwords=\"500\" rows=\"10\" name=\"vfb-field-3245\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField3246\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3246\" class=\"vfb-control-label\">Resolution efforts <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please describe any action taken to resolve this matter prior to contacting Breining Institute.<\/span><textarea id=\"vfb-field-3246\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"10\" name=\"vfb-field-3246\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField3226\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3226\" class=\"vfb-control-label\">Supporting Documentation Upload<\/label><div><span class=\"vfb-help-block\">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.<\/span><input id=\"vfb-field-3226\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" data-max-file-size=\"5000\" data-max-file-count=\"1\" data-allowed-file-extensions=\"pdf\" type=\"file\" name=\"vfb-field-3226\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Complaint Submission <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField3229\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField3230\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3230\" class=\"vfb-control-label\">The undersigned complainant certifies and understands the following:<\/label><div class=\"\"><p>The person submitting this complaint certifies and understands the following::<\/p>\n<ul>\n<li>The person submitting this complaint certifies, under penalty of perjury, that the stated charges within this complaint are true and correct.<\/li>\n<li>If any of the submitted statements are willfully false, the complainant understands that they may be subject to criminal and\/or civil punishment.<\/li>\n<li>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.<\/li>\n<li>The undersigned waives any requirements of confidentiality, and authorizes disclosure of information, as Breining Institute deems necessary to investigate or pursue this complaint.<\/li>\n<li>The undersigned will testify before an administrative board or in a court of law if requested to do so.<\/li>\n<li>The undersigned may be contacted by Breining Institute for additional information relating to this complaint.<\/li>\n<li>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.<\/li>\n<li>Until the complaint is fully investigated and resolved, Breining Institute is not permitted to disclose information regarding the investigation.<\/li>\n<\/ul>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Attestation<\/div><span class=\"vfb-help-block\"><h2><span style=\"color: #008000;\">Attestation<\/span><\/h2>\r\n<h4>By submitting this form, I attest that the information I have provided within this form is true and authentic.<\/h4><\/span><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField3232\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-signature\" id=\"vfbField3233\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3233\" class=\"vfb-control-label\">Signature <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please carefully use this space to sign your name.<\/span><input id=\"vfb-field-3233\" class=\"vfb-form-control vfb-signature-input\" placeholder=\"\" required=\"required\" type=\"hidden\" name=\"vfb-field-3233\" value=\"\"><div class=\"vfb-signature\"><\/div><div class=\"vfb-signature-buttons\"><a href=\"#\" class=\"btn btn-primary\">Reset Signature<\/a><\/div><div class=\"vfb-has-error vfb-signature-error\"><span class=\"vfb-help-block\">Signature is required.<\/span><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField3234\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3234\" class=\"vfb-control-label\">Are you ready to submit this complaint?<\/label><div class=\"\"><p><span style=\"color: #ff0000;\">If you are ready to submit your complaint, select the &#8220;Submit&#8221; button on the bottom of this page.<\/span><\/p>\n<p><span style=\"color: #ff0000;\">Please only select the &#8220;Submit&#8221; button one time.<\/span><\/p>\n<p>Once it is successfully submitted, you will see a message on the screen that the complaint was &#8220;successfully submitted.&#8221;<\/p>\n<p>If you have uploaded documents, it may take additional time for the complaint to be submitted.<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-captcha\" id=\"vfbField3235\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3235\" class=\"vfb-control-label\">Captcha <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"g-recaptcha\" data-sitekey=\"6LdWgN0UAAAAAM_hb1SqmzT2DP4J1X289K2epOVA\"><\/div><input type=\"hidden\" name=\"_vfb_recaptcha_enabled\" value=\"1\" id=\"\"><div class=\"vfb-has-error\" id=\"vfb-recaptcha-error\"><span class=\"vfb-help-block\">reCAPTCHA is required.<\/span><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-submit\" id=\"vfbField3236\"><button id=\"vfb-field-3236\" class=\" btn btn-primary\" placeholder=\"\" type=\"submit\" name=\"_vfb-submit\">Submit<\/button><\/div><div class=\"vfb-clearfix\"><\/div><\/section><\/form>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":10,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-29441","page","type-page","status-publish","czr-hentry"],"_links":{"self":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/29441","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/comments?post=29441"}],"version-history":[{"count":1,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/29441\/revisions"}],"predecessor-version":[{"id":29442,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/29441\/revisions\/29442"}],"up":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/10"}],"wp:attachment":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/media?parent=29441"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}