Appointment Request Please complete the form below to schedule an appointment. I will try my best to accommodate your request and will be in touch ASAP. Enriching Your Life Together Please enable JavaScript in your browser to complete this form.Name of person completing the formE-mail *Client's nameAge *Reason Seeking CounselingPhone NumberComment or Message *Terms of Use *Yes, I want to submit this form By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.MessageSubmit
