Contact

f you are seeking services, please fill out the following information for our team to review. Please provide as much information as you are comfortable doing so. Someone from our office will reach out as soon as possible to discuss your options.

Name *

Phone Number *

E-mail *

Do you have insurance? If so, what insurance do you have? Do you need to use your insurance or are you able to self-pay? *

Do you have unique availability that you would like to let us know about? (specific days or times that work best) *

Clinician preference? *

Are you seeking services due to a court order? *

Presenting concern? *

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. *

Yes, I want to submit this form

Phone

Address:
401 Pasadena Avenue S
St. Petersburg, Florida 33707
Phone:
(727)-495-6302

Email:
therapyforauthenticliving@gmail.com