Client Forms

If you are new to the working with me, please be sure to fill out the following forms, and bring them to your first session. This will help ease you in and allow as much time as possible to focus on you.

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

Release of Health Information

COVID 19 Release & Agreement

Contact Today

Name *

Email *

Phone *

By submitting your phone number, you are authorizing us to send you text messages and notifications. Message and data rates may apply. Reply STOP to unsubscribe

The types of messages sent include scheduling notifications and other related communications, which will occur 24 hours before every appointment, and upon request of consumer. For assistance, consumers can text "Tech Help" to the above mentioned phone number, and a person will assist you.

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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