Therapy Appointment Request Form | Encinitas, CA

To schedule an individual, couples, marriage or family therapy appointment or to obtain additional information about any of these counseling services, please call: 760-634-3188. If I am not able to answer, leave you name and number, please speak slowly and spell your name; I will get back to you within 24 hours.

Your Name*
Email*
Phone*
Preferred Date
Date Format: MM slash DD slash YYYY
Additonal Comments
Terms of Use*
- Yes, I want to submit this form
By 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.