Form

Form
Client Feedback Form

If you've had an experience with a clinician at MindTree Holistic Counseling or the clinic itself that you wish to share, please feel free to leave your feedback in the form below. Feedback helps us improve and enhance your experience!
Name (If you wish to provide it)
Email (If you wish to provide it)
Any feedback you would like to share with us:
I want this content to remain anonymous/private
I'm okay with this "review" being published on the website. (Due to patient confidentiality, all reviews will be posted as "Anonymous Client")
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.
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Client Feedback Form