Appointment Request

Fill out the information below to request an appointment with Bernard Fleming, LPC, LMFT, CGP.

Your Name*
Email*
Phone*
Preferred Date*
MM slash DD slash YYYY
Additonal Comments
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.
Phone
This field is for validation purposes and should be left unchanged.

Your Name*
Email*
Phone*
Your 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.
Comments
This field is for validation purposes and should be left unchanged.