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Wild Five

3787 River Rd. N Suite A,  Keizer OR 97303

PO Box 18180 Salem OR 97305

Appointment Phone: 971-225-5505 

Office Phone: 503-763-1778  (may be forwarded to my cell so please leave a message)

If you have an emergency call 911.

It is helpful to fill out the registration and psychosocial health history forms in advance.  If you are unable to print them here, ask Linda to mail them to you or send them by email.

Please fill out the registration and health information form. 

Available in PDF:


 and Intake Health Info

intake pdf

There are several optional rating sales available on the following link if you have a specific concerns.

Additional objective rating scales

Please use your appointment time wisely by having these filled out in advance.

My Confidential Fax 503-980-7888

Health Information Portability and Accountability Act

Coordination of care with another provider requires a release of information (ROI).  More information can be found on the HIPAA page. 

I have a data base of most of the local providers and may request a release of information as we decided who should be involved in your treatment.  Generally your primary care provider and if you have a therapist.  If there are court ordered custody issues please provide that information as well.   

Release of information forms can be filled out when we meet. I have a database of providers.

Standard Release of Information form.


Change of Insurance

If you need to update your insurance info please fill out the following form and provide a copy of your insurance card(s).

Insurance update.doc
 this may be faxed to 503-980-7888

Please remember information in email should not be considered confidential.