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. 888.218.9731 By contacting Forerunner Counseling via text, you consent to receive text message responses in relation to your initial communication. Message frequency varies. Message and data rates may apply. You may opt out of receiving text SMS at any time by replying STOP or by sending an email to info@forerunnercounseling.com. Reply HELP for Support.