Request an Initial Appointment

Emergency Assistance

We are not able to provide crisis services; if you are experiencing a crisis at this time:

Call the King County Crisis Line: 866-427-4747
Call 9-1-1
Go to your nearest Emergency Room

After this form has been reviewed by office staff and the selected provider(s) you will be called by a staff member for more information or to discuss next steps. We will do our best to do so within one week, and appreciate your patience. Please note that submission of this form is a screening only, and does not establish a patient provider relationship or guarantee acceptance by one of our providers. If we are unable to take you as a patient at this time, we will be happy to provide a few suggestions of alternate providers in the area. Thank you for your interest in seeing one of the providers in our office.

Please note: Individuals aged 13 and older should answer all questions themselves.

Patient First Name

Patient Last Name

Patient Age

Phone Number

This phone number belongs to the patient

Yes No

Contact person's name

Relationship to patient

City you live in

Only Emmanuel Nwabude and Keenan Smith are licensed in Oregon.

Only Keenan Smith is licensed in Kansas.

Only Emmanuel Nwabude is licensed in Arizona and Colorado.

Which provider are you interested in seeing? (check all that apply)

Any available provider

Kiran Gill, ARNP (Female)

Kiran sees patients aged 18 - 64

Keenan Smith, ARNP (Male)

Keenan sees patients aged 10 - 64

Jong Oh, ARNP (Male)

Jong sees patients aged 18 - 85

Emmanuel Nwabude, ARNP (Male)

Emmanuel sees patients aged 10 - 85

Kit (Katherine) Ko, ARNP (Female)

-- Kit is not accepting new patients

Nancy Wagner, ARNP (Female)

-- Nancy is not accepting new patients

Sarah Applegate, ARNP (Female)

-- Sarah is not accepting new patients

If the provider(s) you are interested in seeing is unable to accept you as a patient at this time, would you like the other providers at this office (listed above) to review your information for potential acceptance?

No Yes, I'm open to a provider of any gender Yes. I want to see a female provider, but am willing to see a male provider if no female providers can see me. Yes, but only female providers

By checking this box, no male providers will be considered for your care, unless you selected a male provider above.

Yes, but only male providers

By checking this box, no female providers will be considered for your care, unless you selected a female provider above.

I understand that only Kiran Gil is offering both in person and video appointments. All other providers are only offering video appointments at this time (although you will need to be seen in person at least once per year).

Video appointments are also known as Synchronous Telemedicine. When you call your insurance company to check on your mental health benefits, you should specifically ask about these benefits, and check that the provider(s) you are interested in seeing will be covered.

Insurance Information

None of our Nurse Practitioners are in-network with Medicaid, Apple Health, Molina, etc. None of the providers are accepting Medicare patients. If you wish to talk about the Cash Pay / Out-of-Network rates for any of the providers, please call the office at 425-968-5948, ext 0.

Insurances accepted by Kiran Gill, ARNP. Please check your insurance.

Premera

Regence

Blue Cross / Blue Shield

out-of-state plans, Anthem, etc.

Lifewise

HMA

Aetna

First Choice

Kaiser PPO, Options, and Connect plans

Kiran is NOT in network with Kaiser Core, HMO, or Elect plans.

Out-of-Network / Cash Pay

Insurances accepted by Sarah Applegate, ARNP. Please check your insurance.

Premera

Regence

Blue Cross / Blue Shield

out-of-state plans, Anthem, etc.

Lifewise

Sarah is in network with the Lifewise Primary and Preferred plans. She is not in network with the Alpine plan.

HMA

Aetna

Sarah is not in network with the Aetna Signature Administrators Plan

First Choice

Kaiser PPO, Options, and Connect plans

Sarah is NOT in network with Kaiser Core, HMO, or Elect plans.

Out-of-Network / Cash Pay

Insurances accepted by Nancy Wagner, ARNP. Please check your insurance.

Premera

Regence

HMA

Aetna

First Choice

Kaiser PPO, Options, and Connect plans

Nancy is NOT in network with Kaiser Core, HMO, or Elect plans.

Out-of-Network / Cash Pay

Insurances accepted by Kit Ko, ARNP. Please check your insurance.

Premera

Regence

Blue Cross / Blue Shield

out-of-state plans, Anthem, etc.

Lifewise

Kit is in network with the Lifewise Primary and Preferred plans. She is not in network with the Alpine plan.

HMA

Aetna

First Choice

Kaiser PPO, Options, and Connect plans

Kit is NOT in network with Kaiser Core, HMO, or Elect plans.

Out-of-Network / Cash Pay

Insurance ID #

Please include your alpha prefix, if you have one

Insurance Group #

I acknowledge that it is my responsibility to contact my insurance company to confirm that any provider I wish to see is in-network on my particular plan.

While our providers are in-network with most plans administered by the above companies, there are unique plans that may not include our providers within their network, or the mental health benefits are through another company. (Ex: Premera from Swedish Hospital / Providence is out of network for mental health (except Jong Oh, Keenan Smith, and Emmanuel Nwabude), and First Choice from Evergreen Hospital may be out of network.)

About Your Request

I understand that my potential nurse practitioner's primary role is prescribing and managing medication. While my nurse practitioner may incorporate some psychotherapy interventions (talk therapy) into my medication management appointments, this is NOT meant to be a substitute for individual psychotherapy with a licensed therapist.

I understand that these providers can NOT do neuropsychological assessments (neuropsych testing). Using clinical interview technique these providers can diagnosis and manage meds for conditions such as ADHD, anxiety, depression, bipolar disorder, and other mental health disorders.

What are the issues, concerns, etc. that you would like to receive MEDICATION MANAGEMENT for?

Please be as specific as possible. (Example: Depression, Anxiety, etc.) Please also let us know how long this has been an issue for you.

Please list ALL the medications are you currently taking including: prescription medications, over the counter medications, vitamins, and supplements. Please make sure to list medication name, dosage, and how often you take the medication.

Please list all all psychiatric medications taken in the past.

What is your current prescribing provider's name?

What is your current talk therapist / counselor's name?

Have you ever been hospitalized for psychiatric purposes?

Yes No

Voluntary or Involuntary hospitalization?

Voluntary Involuntary

Please note approximate dates and durations

Do you have history of substance use concerns? (ex: drugs, alcohol, food)

Yes No

Is this a past or current issue?

Past Current

Was / is this drugs, alcohol, or food? Please include approximate dates if in the past

Have you ever self harmed?

Yes No

Is this a past or current issue?

Past Current

Please note approximate dates

Have you ever attempted suicide?

Yes No

Please note date(s) of event

Do you currently have suicidal thoughts?

Yes No

Please note frequency and intensity

Are there any legal issues you are dealing with? (Ex: divorce, restraining order, lawsuit, etc.)

Yes No

What is the issue? Is there anything else from your past?

Do you have any history of violent actions? (Ex: Throwing things, punching walls, road rage, physical fights, etc.)

Yes No

Is this a past or current issue?

Past Current

Please describe the actions

Referral Information

If referred by an individual or agency, please share their name(s) here so that we might thank them!

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Request an Initial Appointment

Emergency Assistance

Insurance Information

About Your Request

Referral Information

Emergency Assistance

Sound Mind Psychiatry

Psychiatric Mental Health Nurse Practitioners