Client Intake Form

January 17, 2018 by TRCCRTTN7663 Leave a Comment

Client Intake Form

205 Avenue I Suite 19
Redondo Beach, CA 90277

(310) 980-7162
traci@tracicrittonphd.com

Send a Message

Name *

E-mail *

Phone

Comment or Message

Terms of Use *

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.

Name

Privacy Policy

A Bright Site by Brighter Vision