Appointment Request Please fill out the form below to request a counseling appointment, I will try to accommodate your request as best as possible. Your Name*Email* Phone*Preferred Date Date Format: MM slash DD slash YYYY Additonal CommentsTerms of Use* 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.