David C. Brillhart, Psy.D.
Helpful Forms

As of 3/30/2020 we are offering Telepsychology due to the COVID-19 please review the informed consent document. Please click to download.

Telepsychology Consent / Info Form

TelePsychology-Informed-Consent.pdf
 

If you are a new client, please complete the following forms and bring them with you to your first therapy session.

Adult Intake Packet

Act II Adult Intake Packet

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

Authorization to Disclose Information Form

 

PHI Act II form

Note: To download Adobe Acrobat Reader for free, click here.

 

 



QUICK LINKS

                               

 


        
Located in the Mid-Valley Pain Clinic, Suite #170 | 3723 Fairview Industrial Dr., SE, Salem, OR, OR 97302, United States
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