Appointment Request

Please complete the form below to schedule an appointment. We will try our best to accommodate your request and will be in touch as soon as possible.

Name

E-mail *

Phone

We will return your call at this number.

Preferred Time and Date

What date and times work best for you (a specific date, mornings, evenings, or anytime)?

Where would you like the therapy to take place?

In Person
Online through a secure video chat
Either one is fine

We offer therapy session at our office or online through a secure video chat platform called Doxy.me. Which do you prefer?

Comment or Message *

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.

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