Make an Appointment: [email protected] | (336) 285-6396

[email protected] | (336) 285-6396
Contact
  • (336) 285-6396
    [email protected]
    • banner image

    Client Forms

    If you are new, please feel free to fill out these intake forms before our first session.

    Client Intake Form

    Information Sheet

    Limits of Confidentiality

    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

    North Carolina and Virginia
     
    (336) 285-6396
    [email protected]

    By submitting this form via this web portal, you acknowledge and accept that 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.