Client Forms

If you are new, please feel free to fill out these intake forms before our first session. These forms can also be filled out during the first session.

If you feel that you would like to collaborate your session with another provider, simply fill out the following form.

Authorization for Release of Information

Contact

Name *

Email *

Phone

SMS Disclaimer

I agree to receive text communication from you. Msg & data rates may apply. Messaging frequency varies. Text STOP at any time to opt out of receiving SMS text messages or HELP for assistance.

Preferred Date & Time

Comment or Message

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. *