Ginkgo Wellness Logo

Melanie Kawashima Velez

Doctorate of Nursing Practice

Board-Certified PMHNP

Ginkgo Wellness Logo

Melanie Kawashima Velez

Doctorate of Nursing Practice

Board-Certified PMHNP

New Patient Questionnaire

Welcome

Please complete this form so we can contact you about scheduling the best appointment type for you.

If we are not contracted with your health insurance provider, we will create a Good Faith Estimate for you to pay out of pocket and a Super Bill so you may seek reimbursement from your health insurance provider

* indicates a required field

Patient Information

Contact Information

Can we leave a message? *

Insurance

Services

Type of Services Seeking (Click all that apply) *

Please describe the reason you are seeking services *

Do you have a previous Mental Health Diagnosis or suspected Mental Health Conditions? Please describe:

Please select any CURRENT or PAST diagnosis:

Please list any other medical diagnosis/conditions here

Current Providers

Do you have a current psychiatric prescriber? *

Do you have a Primary Care Physician? *

Please note that while *not* having a PCP will not stop our initial intake process, in order to remain an active patient at Ginkgo Well Care, establishing with a PCP will be required. *

Do you have a current therapist? *

Ginkgo Well Care does NOT offer individual, couples, or group therapy / counseling services. *

Mental Health History

Are you (the patient) your own decision maker? *

Have you (the patient) ever attempted suicide? *

Have you engaged in self injurious behavior in the past 12mos? *

Have you ever been hospitalized for a mental health condition? *

Have you ever been on a mental health commitment? *

Are you currently on a mental health commitment? *

Have you been aggressive in the past 12mos due to your mental health? *

Additional Details

If "yes" selected for any of the above, please provide any details you are comfortable with sharing.

Any other information you'd like to share?

How did you hear about us?