Client Forms

If you are new, please print and fill out these intake forms and bring bring them with you to our first appointment. If you are unable to complete them at home, it is fine to fill them out in the office.

Intake Information & Patient Services Agreement

Functioning and Symptom Scale

Policies & Practices to Protect the Privacy of Your Health Information

If you feel you would like for me to collaborate with another treatment provider on your care, or if you wish for me to share treatment information with a family member or some other party, simply fill out the following form.

Authorization to Release Information Form

Contact Today



8330 Meadow Road Suite 200
Dallas, TX 75231

drlarry@hanselka.name
(817) 266-4260

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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.