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(804) 214-6363   |   outenlpc@gmail.com

Cheryl Outen

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Client Forms

If you are new to therapy, please be sure to fill out the following forms.  You will be able to upload them during your first session.  This will help ease you into therapy, and allow as much time as possible to be spent focusing on you.

Individual:
Intake (Adult)
Intake (minor)
Informed consent (Adult)
Informed consent (Minor)
Authorization for Recurring CC Charges

Telehealth:
Telehealth Informed consent
Telehealth Crisis Protocol

Contact Today

Dr. Cheryl Outen



Phone: (804) 214-6363
outenlpc@gmail.com

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.

Mosaic Healing


Phone: (804) 214-6363
Email: outenlpc@gmail.com


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“Be faithful to that which exists within yourself.”
– André Gide

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