OHT_intake-form_10.2.2017

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Yes, please contact me

By reaching out to us through the website you agree to be contacted by one of the therapists and/or the practice manager. Please note that it may take us at least 5 to 7 business days to respond to you. If you do not hear back from us within that timeframe, please email us at info@openedhearttherapy.com to confirm receipt of your message. Please also check your spam folder. We take responding to inquiries very seriously and will make every effort to respond to you as quickly as possible.

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.

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