Petition for Order Modification
Board for Professional Counselors, Marital and Family Therapists,
and Clinical Pastoral Therapists
Petitioner's Name: _
Petitioner's Mailing Address: _
Petitioner's E-Mail Address: _
Telephone Number: _
Attorney for Petitioner: _
Attorney's Mailing Address: _
Attorney's E-Mail Address: _
Telephone Number: _
The petitioner respectfully represents that for the following reasons, as substantiated by the attached documentation, the identified provisions of the attached disciplinary order are impossible for me to comply with:
Note - You must enclose all documents necessary to prove your request including a copy of the original order. If any of the proof you are relying upon to show impossibility is the testimony of any individual, including yourself, you must enclose signed and notarized statements from every individual you intend to rely upon attesting, under oath, to the reasons why compliance is impossible. No documentation or testimony other than that submitted will be considered in making an initial determination on, or a final order in response to, this petition.
Respectfully submitted this the _ day of_, 20_.
_________________________________
Petitioner's Signature
Tenn. Comp. R. & Regs. 0450-01-.15
Authority: T.C.A. §§ 4-5-202, 4-5-204, 63-22-102, 63-22-110 and 63-22-111.