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 and State you live in

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, any provider of either 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.

Yes, but only male providers

By checking this box, no female providers will be considered for your care.

I understand that Kiran Gill and Jong Oh are offering video as well as in person appointments. Emmanuel Nwabude and Keenan Smith 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

Insurance ID #

Please include your alpha prefix, if you have one

Insurance Group #

I acknowledge that I need 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 OON for mental health, and First Choice from Evergreen Hospital is OON.)

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 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