Existing Patient

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Date
MM slash DD slash YYYY
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Date
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Date Submitted
Are You An Existing Patient?*
- Yes
- No
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What is your MRN?
Patient's Last Name*
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Date of Birth*
MM slash DD slash YYYY
Date of Birth*
Month
Day
Year
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Age*
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Date
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Date of Birth copy
We apologize for the inconvenience, we only see patients 16 years of age or older.
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Do you have a new phone #?*
- Yes
- No
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New Phone #*
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Same Phone #*
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What is your email address?*
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Do you have a new email?*
- Yes
- No
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Have you moved?*
- Yes
- No
Street Address*
City*
State*
State
Zip/Postal Code*
Upload front image of your Driver's License.*
Accepted file types: pdf, jpg, jpeg, Max. file size: 120 MB.
Upload back image of your Driver's License.*
Accepted file types: pdf, jpg, jpeg, Max. file size: 120 MB.
Please Note: There may be a slight delay of 1-2 minutes in processing your attachments based on their sizes. You're requested only to attach them once and wait for them to load.
Your understanding is greatly appreciated.
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Do you have any changes in Medication?*
- Yes
- No
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Do you have any changes in Medication? (YES)
Medications Name*
Dose*
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Side Effects*
Do you have an additional Medication Changes?*
- Yes
- No
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Medications Name*
Dose*
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Side Effects*
Do you have an additional Medication Changes?*
- Yes
- No
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Medications Name*
Dose*
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Side Effects*
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Do you have a new Primary Care Physician?*
- Yes
- No
Who is your Primary Care Provider?*
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When was your last visit to your Primary Care Provider?
When was your last visit to your Primary Care Provider?
MM slash DD slash YYYY
When was your last Health & Physical?
MM slash DD slash YYYY
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Copy Date Health & Physical?
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Do you have a New Insurance?*
- Yes
- No
Upload front image of your Insurance Card*
Accepted file types: pdf, jpg, jpeg, Max. file size: 120 MB.
Upload back image of your Insurance Card*
Accepted file types: pdf, jpg, jpeg, Max. file size: 120 MB.
Please Note: There may be a slight delay of 1-2 minutes in processing your attachments based on their sizes. You're requested only to attach them once and wait for them to load.
Your understanding is greatly appreciated.
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Do you have a New Secondary Insurance?*
- Yes
- No
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Secondary Insurance*
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Secondary Insurance ID #
Secondary Insurance Group #
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Appointment Reason*
Other Reason
Appointment Reason Description*
Please share your treatment Goals ?
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What is your long term treatment goal?
Suicidal Ideations (CCSR)
In the past month have you wished you were dead or wished you could go to sleep and not wake up?*
- Yes
- No
In the past month have you actually had any thoughts of killing yourself?*
- Yes
- No
In the past month have you ever done anything, started to do anything, or prepared to do anything to end your life?*
- Yes
- No
Immediate Steps for Your Safety

Based on the outcomes of your recent safety assessment at Mid Cities Psychiatry, we urge you to take the following immediate steps:

If you need immediate help, please call 911.
or Visit an Emergency Room Near You
or Reach out to family or friends for support during this time.
or Contact the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255)
or text "HELLO" to 741741 for 24/7 confidential counseling.

For more information, visit our Patient Resources webpage.
In the past month have you had these thoughts and had some intention of acting on them?*
- Yes
- No
In the past month have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?*
- Yes
- No
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Have you ever done anything, started to do anything, or prepared to do anything to end your life?
- Yes
- No
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Was this within the past three months?
- Yes
- No
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Patients categorized as
Homicidal Ideations
Are you having Homicidal Ideations?*
- Yes
- Yes and I am afraid I may act on them
- No
PLEASE Go To Your Nearest Emergency Room or Call 911.
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Do You Have a Plan?*
- Yes
- No
What is your plan?*
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Dependent Care Resources
Dependent Care Resources
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Do you need resources for the care of your dependents?
- Yes
- No
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Psychiatric Advance Directive Question:
Psychiatric Advance Directive
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Do you have a Psychiatric Advance Directive?
- Yes
- No
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Please attach it here
Accepted file types: pdf, Max. file size: 120 MB.
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Would you like to create one?
- Yes
- No
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Legal Need Resources Question
Legal Need Resources
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Are you in need of legal assistance or support?
- Yes
- No
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Vocational Need Resources Question
Vocational Need Resources
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Do you need vocational assistance or support?
- Yes
- No
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Consent*
I Agree (Mandatory) I understand that Mid Cities Psychiatry may request a Urine Drug Screen, which I must provide either at Mid Cities Psychiatry's office or at an accredited laboratory within 48 hours of their request. If the screen detects substances not prescribed (including THC, Delta 8, Kratom, and Alcohol) or if it shows a lack of prescribed medications, Mid Cities Psychiatry reserves the right to decline any further prescriptions.*
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I understand that Mid Cities Psychiatry may request a Urine Drug Screen, which I must provide either at Mid Cities Psychiatry's office or at an accredited laboratory within 48 hours of their request. If the screen detects substances not prescribed (including THC, Delta 8, Kratom, and Alcohol) or if it shows a lack of prescribed medications, Mid Cities Psychiatry reserves the right to decline any further prescriptions.*
- I Agree (Mandatory)
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RCN
I acknowledge Mid Cities Psychiatry's policy for rescheduling, canceling, and no-shows. I must inform Mid Cities Psychiatry at least 24 business hours before my appointment for changes. Weekends, long weekends, and national holidays are excluded as they are non-business hours. Non-compliance will incur charges as per the RCN Fee Schedule:
    • 40 minutes meds management appointment no-show fees would be $150.00
    • Psychologists' appointment no-show fees would be $150.00 per hour
    • Therapist's appointment no-show fees would be $150.00
    • 20 minutes meds management appointment no-show fees would be $75.00
To avoid these charges, please reschedule or cancel in more than 24 business hours in advance, considering our office closure on weekends and holidays.
An appointment Rescheduled or Canceled within 24 business hours of your appointment or No-Show at the appointment will be billed as per the following RCN Fee Schedule. Please be advised calls made 24 hours before the appointment on weekends or long weekends or on National Holidays when our offices are closed are not 24 Business Hours. So to avoid our billing department billing you RCN Fee, please call in more than 24 business hours.*
- I Agree (Mandatory)
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Do you have a Psychotherapist?*
- Yes
- No
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Name*
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Email*
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Phone Number*
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Fax Number*
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City*
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State*
State
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Date of last visit*
MM slash DD slash YYYY
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Do you have a Psychologist?*
- Yes
- No
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Name*
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Email*
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Phone Number*
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Fax Number*
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City*
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State*
State
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Date of last visit*
MM slash DD slash YYYY
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TMS
Mid Cities Psychiatry provides Transcranial Magnetic Stimulation aka TMS Therapy. TMS Therapy is an alternative treatment for patients suffering from depression for whom medication has proven ineffective. and provides new hope for people who want to reduce or possibly eliminate the use of prescription medications to treat their depression.
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Would you like to be contacted by a patient advocate to know more about TMS Therapy?*
- Yes
- No
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Please specify your preferred future appointment date?
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Providers *
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Appointment Date *
MM slash DD slash YYYY
Subject to your insurance eligibility (if you have insurance), our appointment team
will call you ASAP to schedule an appointment for you on the next available appointment slot.
Please note that we cannot guarantee the requested appointment date. Our dedicated Appointment Team
will contact you to schedule an appointment. This is subject to your insurance eligibility. Rest assured, your needs are important to us.
If you don't hear from us within 24 business hours, please contact us at 817-488-8998 ext 2 or e-mail us at info@MidCitiesPsychiatry.com.
Please Note, processing your form may take 1-2 minutes.
To avoid delays, kindly press the submit button only once and wait for the thank you message.
We appreciate your patience.

Existing Patient

Do you have any changes in Medication? (YES)

Suicidal Ideations (CCSR)

Homicidal Ideations

Dependent Care Resources

Dependent Care Resources

Psychiatric Advance Directive Question:

Psychiatric Advance Directive

Legal Need Resources Question

Legal Need Resources

Vocational Need Resources Question

Vocational Need Resources

RCN

TMS

Please specify your preferred future appointment date?

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