Therapy Appointment Request To schedule an appointment or obtain additional information about these counseling services, please fill out the form below or leave a voicemail. I will do my best to respond within 36 hours Monday through Friday. Please enable JavaScript in your browser to complete this form.Name *E-mail *PhoneComment or Message *Terms 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.PhoneSubmit