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

Contact Information and Preferences

Preferred days and times for us to contact you

Phone number

May I leave a message?

Yes No

Email address

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

Would it be OK if we send a copy of your initial evaluation to your referring provider

Yes No

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

Yes No

How are you related to the person who referred you?

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.

What insurance do you have?

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