Client Forms

If you’re a new client, please complete the following forms and send them to me via email or bring them to your first therapy session.

Client Intake Forms

If you feel that you would like to collaborate your therapy with another provider, simply fill out the following form.

Authorization for Release of Information

 

Contact Today



6750 Hillcrest Plaza Drive, Suite 304
Dallas, TX 75230

monica@urbaniakwellness.com
(214) 347-9765

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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.