Schedule an EMDR or CBT Counseling Appointment | North East, MD

Please complete the form below to schedule an appointment. We will do our best to accommodate your requests and will be in touch within 72 business hours.

Name *

E-mail *

Phone *

Preferred Time and Date *

Preferred Clinician

Comment or Message *

Disclaimer

The inbox for this form is only reviewed at certain times of the day and is not appropriate for crisis messages. If you are in crisis, please call 911 or go to your nearest emergency room. By clicking this check-box, I acknowledge that I have read and understood this statement.

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.

Comment