Name *

First Name

Last Name

Inquiring about

Individual Therapy

Group Therapy

Consultation

Speaking Engagement

Other

Terms of Use

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.

Yes, I want to submit this form & agree to the terms of use