Make an Appointment: 860-920-4420 | [email protected]

[email protected] | 860-920-4420
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10 Oak Street, Unit 9, Needham, MA, 02492
41 Mechanic Street, Flr 2, Windsor, CT, 06095
[email protected]rkcounseling.com | 860-920-4420

  • 860-920-4420
    [email protected]

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    Client Forms / Records Request

    Please complete the following forms prior to your first appointment. If you have any questions feel free to get in touch with us through the contact page on this site.

    Intake Questionnaire

    Informed Consent

    Credit Card Authorization

    If you would like us to obtain or release information to a 3rd party please complete the Release of Protected Health Information below.

    Release of Protected Health Information

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    860-920-4420
    [email protected]

    10 Oak Street, Unit 9
    Needham, MA, 02492

    41 Mechanic Street, Flr 2
    Windsor, CT, 06095

    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.