Request Your Application Please fill out the form below to request the Membership Application packet. Our team will reach out to you shortly to send this to you. Please enable JavaScript in your browser to complete this form.Your Name *FirstLastLicense *LMFTLPCCPsychologistPsychiatristCNPLISWLCSWNone of the AbovePlease choose your current license from the list here. If none of these are applicable to you, please choose "None of the Above"Your Email *Your Phone Number *Desired Membership *Full MemberAffiliate MemberAssociate MemberAgency MemberTerms 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.PhoneSubmit
