Appointment Request

To request an individual, children, couples, marriage or family therapy appointment or to obtain additional information about any of these counseling services, please fill out the form below or give me a call.

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    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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