Appointment Request Please complete the form below to schedule an appointment. I will contact you within 24 to 48 hours and will try my best to accommodate your request. Please enable JavaScript in your browser to complete this form.Name *E-mail *Phone *Preferred Time and Date *Comment or MessageI am also interested in possibly working with an LPC Associate in your office for a reduced out-of-pocket feeYesTerms of Use *Yes, I want to submit this formBy 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.CommentSubmit
