Make an Appointment: kbergacs@myplaceforpeace.com | (908) 751-1208
(908) 751-1208

kbergacs@myplaceforpeace.com

Client Forms

If you are new, please feel free to fill out these intake forms before our first session.

Consent for Treatment of Minor

Child Intake Form

Authorization for Electronic Communication

Adult Intake Form

Limits of Confidentiality

Office Policies

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

Authorization to Release Information

 

Contact Today



87 Park Avenue
Flemington, NJ 08822

kbergacs@myplaceforpeace.com
(908) 751-1208

Got Questions?
Send a Message!

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.