Apply to Join Group Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *Referred by:Health Care ProviderWebsitePsychology TodayTherapistFriends/FamilyOtherWhat areas of your life are most affected?What would you like to accomplish from being part of the group?Terms of Use *Yes, I want to submit this formBy 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.NameSubmit