Thanks

Thank you for contacting me! I will be in touch soon.

Name *

Email *

Phone

Yes, opt-in
No, opt-out

Would you like to opt-in to receive text messages from Back to Balance Counseling? Opt-in is optional. By opting-in you agree to receive recurring text messages regarding appointment reminders and scheduling, billing, insurance, etc. Message frequency varies. Message and data rates may apply. For help and support call 773-242-8898 or email info@backtobalancecounseling.com. Reply STOP to any text message you receive from Back to Balance Counseling to opt-out at any time. For more information, visit our privacy policy at Back to Balance Counseling or our terms and conditions at https://backtobalancecounseling.com/wp-content/uploads/2025/06/privacy-policy.pdf

Comment or Message *

Yes, I want to submit this form & agree to the terms of use. *

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.