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. If this is a mental health emergency, please visit your local hospital ER or call 911. Please enable JavaScript in your browser to complete this form.Name *Gender Identity *PronounsAge *I am 18 or olderI am under 18 and will require my parent/guardian's consentE-mail *PhoneMay I leave a message at this number? *YesNoHow would you prefer to be contacted? *PhoneEmailI am interested in: *Couples or Marriage CounselingLife CoachingFamily TherapyIndividual Therapy for MyselfIndividual Therapy for Someone Important to MeClinical SupervisionComment or MessageTerms of Use *Yes, I want to submit this formBy 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.EmailSubmit
