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Brain Health

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, I can mail them to you or send them by email.

Please fill out the registration and health information form. 

Available in WORD format:


Keizer forms

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(s) cards.

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

Please remember information in email should not be considered confidential.