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Behavioral Sciences Regulatory Board

712 South Kansas Avenue

Topeka, Kansas 66603-3817

(785) 296-3240

(785) 296-3112 (FAX)

Page 1 of3

REPORT OF ALLEGED VIOLATION

INSTRUCTIONS: (Please type or print legibly)

Please furnish all identifying information, including addresses and telephone numbers, for the

complainant, witnesses, and the professional against whom the report is being filed. Please complete

all pages of this form. Additional pages may be added if necessary

C01\IPLAINANT: PERSON FILING REPORT

NAME < : . \ ~ ~ \ ~First Middle

~'Y'\) r~'t..~

Last

ADDRESS: \?O. ~~ L \G l-~ ;1O~li\Street (Apt, Suite #) City

~s loblcO(fState Zip Code

HOME PHONE: (7~ \ S '- t S " " - 3\f I 1- WORK PHONE: ( ) _

Best time to contact you would be') a.m./p.m. to a.m./p.m.

May we contact you at your place of employment'? Yes __ No__

RESPONDENT: PROFESSIONAL AGAINST \\'H01\1 THE REPORT IS FILED

NAME: \)C4...~\.~ ~~~~-e.. . ,*~rFirst Middle Last

ADDRESS: CfoC(. q" - 0 "t'-e..-y\\:h ) ~\2 e.~t K.~ ~ l D b D ~Street (Apt, Suite #) City State Zip Code

PHONE #~) .;23 Y -4 T '- 13 AGENCY NAME: ~ e/~-Prc>l'd)\",(un~ ~

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Behavioral Sciences Regulatory Board

712 South Kansas Avenue

Topeka, Kansas 66603-3817

(785) 296-3240

(785) 296-3112 (FAX)

Page 2 of3

RELEASE OF INFORMATION AUTHORIZATIONFor the purpose or investigation of complaints and any suhsequent disciplinary action

I hereby waive my privilege of confidentiality concerning my care and treatment, or the care and

treatment of my minor child or ward, and authorize any person, including, but not limited to, mental

health care agencies, mental health providers, health care providers, clinics, employers (past and

present), attorneys, insurance companies, government agencies, or other public or private agency to

release to the Kansas Behavioral Sciences Regulatory Board, its representative, agents or employees,

any and all information about me or my minor child, including documents, reports, records, files,

testimony or any other document regardless of form or content

PERSONAUTHORIZING RELEASE:

NAME:~~~,r"C:"J::::>~~ (~.....::.~

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"..'r.__

Page 3 of3

NARRATIVE:

Behavioral Sciences Regulatory Board

712 South Kansas Avenue

Topeka, Kansas 66603-3817

(785) 296-3240

(785) 296-3112 (FAX)

Please describe in detail all allegations against the person whom you are filing the report. Describe

each incident with specific dates and include names of witnesses. Include your relationship to the

LicenseelProfessional, and if you were a client, the reason you saw the professional (i.e. was it court

ordered, was the therapist court appointed, or was the therapist a mediator). Attach copies of any

documents you have concerning the allegations. Use additional sheets if necessary.

(Reminder: Who, What, When, Where, Why and How.)

DATE: \0le i 1(X)(yf PERSON WRlTING NARRATIVE:

C J~l((;:G n-.'ort:> ~'-?t,--I

~~~ ~~ ~~~~Q0.-

cP

The statements I have made are true and correct to the best of my knowledge and belief. I

acknowledge that the Behavioral Sciences Regulatory Board may provide a copy of this form to the

person against whom the allegations are made. I also agree to testify in any hearings that may arise

as a result of these allegations. _ _ C -- ~

DATE ~DI , /';).DO"1 SIGN~~'--'-'::~~

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fax: 785-296-3112 and website complaint.

Graft, payola, churning, RICO, malpractice, incompetence, dereliction, anti-trust

violation. fraud, misfeasance, malfeasance, bribery, price-fixing, unfair trade practices,

maltreatment, negligence, abuse, therapeutic jurisprudence.

Since his 'one sided' report 2004 and the ex-parte order as a 'result' of his report. He was

removed from this case in July 2004 however, several times this past few years he

'interceded' on behalf of the acting GAL and 'abusers' attorney's to continue to destroy

and maintain 'complete' separation other than the most restrictive and oppressive of

conditions of my daughter and I.

See attached records from Feb. 3rd, 2007 to Sept. 23rd

. 2007.

"Parental alienation"- is an understatement - hearsay, by and through his powers as a

Judicial-MHP taking his direction from the abusers attorneys'. He has and continues to

interfere with parent/child access.

There exists- NO 'finding of fact' that mother is nor has EVER been alleged to be a

threat to her child, not ever' Four years .. gone. A child's childhood stolen, exploited, by

politicking,-'bed swapping,' bottom feeders for increased litigation and increased

financial personal gain.

As a DIRECT result of the unethical, immoral actions of David Rodeheffer, this case has

received National attention and is currently the 'lead plaintiff in a suit to the 'Inter-

American Commission Human Rights'- for human right violations [supported by leading

National and State organizations], filed May 11, 2007.

See complete petition with exhibits here

www.StopFamilyViolence.org

Kansas is hard copy signor to the complaint, press release here:

http://www .kcsdv. org/psmothers. html

David Rodeheffer is the absolute epitome of incompetence, evil-profiteering at the cost

of the very children he is supposed to protect and continues to do- is beyond criminal and

appalling, without any 'conscious' as to the 'irreversible' damage and extent of the

trauma he has and still is causing, my child and 1.

www.StopFamilyViolence.org

Claudine Dombrowski

P.O. Box 4974, Topeka, KS 66604

SaH, ACP