A Mindful Path to Mental Health - Appointment Request

Emergency Assistance

A Mindful Path to Mental Health is a small practice, and is not equipped to manage conditions that require urgent care of 24/7 treatment. If you need emergency assistance:

If you're in immediate danger call 911
For urgent psychiatric evaluation, contact Sutter Center for Psychiatry at 916-386-3620
if you’re not in immediate danger, but need to speak to someone right away, we recommend for you to contact the National Suicide Prevention Lifeline at 1-800-273-8255

Patient Information

First name

Last name

Preferred name (if applicable)

Date Of Birth

Gender

Pronouns used

Primary Phone Number

Secondary Phone Number

May I leave a message?

Yes, Ok to leave a message on either phone Ok to leave a message on primary phone only No, please do not leave me messages

Is it OK for me to text you if needed?

Yes No

Email address

Emergency Contact Name

Emergency Contact Phone Number:

Relationship

About your Appointment Request

If there's anything else about your symptoms or the reason for your visit that you would like Dr. Bonilla to know?

How did you hear about us?

I have seen Dr. Bonilla before I was referred by a healthcare provider I was referred by a friend or family member I found Dr. Bonilla while doing research about my symptoms, diagnosis or treatment options Advertisement

Please specify name of the person who referred you

Referring provider's phone number

How are you related to the person who referred you?

Is the person who referred you a current patient of Dr. Bonilla

Yes No

Please specify name the website you found us on

Please specify name the advertisement or website you found us on

If you were are switching care from another psychiatrist to Dr. Bonilla, please request that your current or most recent psychiatrist send Dr. Bonilla a copy of your records. You may sign their release of information form, or ask us for one.

Health Care Information

Who is your Primary Care Physician?

Primary Care Doctor's Phone Number

Who is your therapist/counselor?

Therapist's phone number

Do you see any other specialists on a regular basis?

Specialist phone number

Primary Pharmacy

Pharmacy Phone Number

Primary Pharmacy Address/location

Secondary Pharmacy

If applicable

Pharmacy Phone Number

Secondary Pharmacy Address/location

Insurance Information

Primary Insurance

Name of Insurance Holder

If different from patient

Secondary Insurance

Name of Insurance Holder

If different from patient

Please Upload a Photo of your Driver's License or ID card

Add file

Please upload a file

Please Upload a Photo of your Insurance Card Please make sure to include picture of Front AND Back

Add file

Please upload a file

Please Upload a Photo of the Driver's License or ID card of the insurance holder (if applicable)

Add file

Please upload a file

Comments

Thank you for choosing us for you mental health care needs. We look forward to seeing you soon!

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Emergency Assistance

A Mindful Path to Mental Health is a small practice, and is not equipped to manage conditions that require urgent care of 24/7 treatment. If you need emergency assistance:

If you're in immediate danger call 911
For urgent psychiatric evaluation, contact Sutter Center for Psychiatry at 916-386-3620
if you’re not in immediate danger, but need to speak to someone right away, we recommend for you to contact the National Suicide Prevention Lifeline at 1-800-273-8255