Initial Appointment Request for Counseling Services, Beachwood, Ohio

Name *

Email *

Phone *

What brings you to seek services? *

Which therapist(s) are you interested in working with

How are you paying for services? *

How did you hear about us?

Days Requesting

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Please share anything else you would like for us to know

Terms of Use *

Yes, I want to submit this form

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.