Appointment Request

To schedule an individual, children, couples, marriage or family therapy appointment; to pre-register for a support group or to obtain additional information about any of these counseling services, please fill out the form below or give us a call.

Please do not include confidential or private information regarding your health condition in this form or any other form found on this website.This form is for general questions or messages to the practitioner.

  • MM slash DD slash YYYY
  • :
    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.
  • This field is for validation purposes and should be left unchanged.