Appointments for Counseling | Play & Art Therapy

Please complete the form below, call 215-352-4400, or email to schedule an appointment.

“Understand. Heal. Grow. We Can Do This Together“

First Name *

Last Name *

E-mail *

Phone

Your current location: City and State *

How did you hear about me? (Referral, google search, social media, etc.) *

What brings you to therapy at this point in your life? (Give me an idea of what you’re struggling with) *

What are you hoping to experience in therapy? *

What days/times work best for you for the video consult call? *

Is there anything else you’d like to share?

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

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