New Patient

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Date
MM slash DD slash YYYY
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Date
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Date Submitted
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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dateofbirth copy
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Age
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We apologize for the inconvenience, we only see patients 16 years of age or older.
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Do you have an open legal case or court case? Workers Compensation or Child Protective Services (CPS) Hearing?*
- Yes
- No
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We apologize for the inconvenience, we do not specialize in these matters and we cannot make the appointment.
We apologize for the inconvenience, we do not specialize in these matters and we cannot make the appointment.
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Are you already ON any pain-control medication such as Hydrocodone, Percocet, Tylenol w/ Codeine, Pain-controlling patches, Opioids, etc.? Please be advised that we will NOT be able to prescribe any Benzodiazepines such as Xanax, Klonopin, Valium, or Ativan due to DEA regulations.*
- Yes
- No
Please contact our Appointment Team at 817-488-8998 ext 2 to further assist you.
check1*
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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check2*
I Agree (Mandatory) I acknowledge that coming to appointment does not guarantee that control-medication will be prescribed. It’s up to the Provider’s discretion when they meet the patient.*
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I acknowledge that coming to appointment does not guarantee that control-medication will be prescribed. It’s up to the Provider’s discretion when they meet the patient.*
- I Agree (Mandatory)
check3*
I Agree (Mandatory) I acknowledge that eligibility for a FormFill Appointment requires a minimum of 5 previous appointments and an association with the clinic for at least 5 months. I will not request a FormFill Appointment if I do not meet these criteria, specifically if: I have been associated with the clinic for 5 months but have had fewer than 5 appointments, or I have had 5 appointments but my association with the clinic is under 5 months.*
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I acknowledge that eligibility for a FormFill Appointment requires a minimum of 5 previous appointments and an association with the clinic for at least 5 months. I will not request a FormFill Appointment if I do not meet these criteria, specifically if: I have been associated with the clinic for 5 months but have had fewer than 5 appointments, or I have had 5 appointments but my association with the clinic is under 5 months.*
- I Agree (Mandatory)
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RCN (Rescheduling / Cancellation / No-Shows) Policy:

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)
Cell Number*
Home Number
Email*
Street Address*
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City*
State*
State
Zip/Postal Code*
Appointment Reason*
Appointment Reason Description*
Other Reason*
Please share your treatment Goals ?
How would you like to pay ?
- Self-pay
- Primary Insurance
Please select the type of identification you would like to use.*
- Driver’s License
- Government ID
- Passport/Passport Card
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Please select the type of identification you would like to use.*
Upload front image of your Identification card*
Accepted file types: pdf, jpg, jpeg, Max. file size: 120 MB.
Upload back image of your Identification*
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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Primary Insurance
Primary Insurance*
Other Insurance*
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Primary Insurance ID #*
Primary Insurance Group #
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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Secondary Insurance
Secondary Insurance
Secondary Insurance ID #
Secondary Insurance Group #
Please select the type of identification you would like to use.*
- Driver’s License
- Government ID
- Passport/Passport Card
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Please select the type of identification you would like to use.*
Upload Front of your ID*
Accepted file types: pdf, jpg, jpeg, Max. file size: 2 GB.
Upload back of your ID*
Accepted file types: pdf, jpg, jpeg, Max. file size: 2 GB.
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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How Did You Hear About Us*
Name*
Specialty*
Phone Number*
Fax Number*
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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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In the past month 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
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Are you having Homicidal Ideations? old*
- Yes
- Yes and I am afraid I may act on them
- No
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.
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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Generalized Anxiety Disorder Questionnaire ( GAD-7 )
How often have you been bothered by the following problems? As you answer each question, select the radio button that best describes how you have felt and conducted yourself over the past 2 weeks.
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1. Feeling nervous, anxious or on edge?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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2. Not being able to stop or control worrying?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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3. Worrying too much about different things?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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4. Trouble relaxing?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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5. Being so restless that it is hard to sit still?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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6. Becoming easily annoyed or irritable?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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7. Feeling afraid as if something awful might happen?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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If you checked off any of the problems, Not difficult at all how difficult have these problems made it for you to do your work, Somewhat difficult take care of things at home, Very difficult or get along with other people? *
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If you checked off any of the problems, Not difficult at all how difficult have these problems made it for you to do your work, Somewhat difficult take care of things at home, Very difficult or get along with other people? *
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Your GAD Scale Total Score Is
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Anxiety level based on score is
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Anxiety level based on score is
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Anxiety level based on score is
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Anxiety level based on score is
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Anxiety level based on score is
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Have you done Connors (ADHD) Testing or Personality Assessment Inventory Testing before? Both these tests are computer-based psychological evaluations designed to measure cognitive abilities, personality traits, emotional states, and behaviors.*
- Yes
- No
Please make sure to submit your previous Connors (ADHD) Testing or Personality Assessment Inventory results soon after your appointment is scheduled
at Mid Cities Psychiatry.
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Are you interested in learning more about Connors (ADHD) Testing or Personality Assessment Inventory Testing?*
- Yes
- No
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Rapid Mood Screener (RMS)
Are you among the millions of people who have depressive symptoms? Answer the following questionnaire about your medical history so that it can be provided to your provider or nurse to assist in an important conversation about your mood. Please select one response for each question. You can complete the RMS in less than 2 minutes.
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1. Have there been at least 6 different periods of time (at least 2 weeks) when you felt deeply depressed?*
- Yes
- No
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2. Did you have problems with depression before the age of 18?*
- Yes
- No
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3. Have you ever had to stop or change your antidepressant because it made you highly irritable or hyper?*
- Yes
- No
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4. Have you ever had a period of at least 1 week during which you were more talkative than normal with thoughts racing in your head?*
- Yes
- No
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5. Have you ever had a period of at least 1 week during which you felt any of the following: unusually happy; unusually outgoing; or unusually energetic?*
- Yes
- No
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6. Have you ever had a period of at least 1 week during which you needed much less sleep than usual?*
- Yes
- No
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Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form (Q-LES-Q-SF)
During the past week how satisfied have you been with your:
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1. Physical health?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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2. Mood?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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3. Work?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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4. Household activities?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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5. Social relationships?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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6. Family relationships?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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7. Leisure time activities?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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8. Ability to function in daily life?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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9. Sexual drive, interest and/or performance?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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In what aspect of your Sexual drive, interest and/or performance?*
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10. Economic status?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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11. Living/housing situation?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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In what aspect of your Living/housing situation?*
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12. Ability to get around physically without feeling dizzy or unsteady or falling?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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In what aspect of your vision in terms of ability to get around physically without feeling dizzy or unsteady or falling?*
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13. Your vision in terms of ability to do work or hobbies?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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In what aspect of your vision in terms of ability to do work or hobbies?*
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14. Overall sense of well being?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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15. Medication? (If not taking any, just leave item blank.)
- Very Poor
- Poor
- Fair
- Good
- Very Good
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16. How would you rate your overall life satisfaction and contentment during the past week?*
- Very Poor
- Poor
- Fair
- Good
- Very Good
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PIF
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Previous Psychiatric Diagnosis
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Have you been previously diagnosed with a psychiatric disorder?*
- Yes
- No
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Diagnosis*
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Year Diagnosed*
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Treating Provider*
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Other Reason*
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Do you have an Additional Previous Psychiatric Diagnosis?*
- Yes
- No
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PPD-2
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Diagnosis*
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Year Diagnosed*
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Treating Provider*
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Other Reason*
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Do you have an Additional Previous Psychiatric Diagnosis?*
- Yes
- No
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PPD-3
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Diagnosis*
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Year Diagnosed*
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Treating Provider*
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Other Reason*
Do you have an Additional Previous Psychiatric Diagnosis?*
- Yes
- No
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PPD-4
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Diagnosis*
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Year Diagnosed*
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Treating Provider*
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Other Reason*
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Do you have an Additional Previous Psychiatric Diagnosis?*
- Yes
- No
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PPD-5
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Diagnosis *
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Year Diagnosed *
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Treating Provider*
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Other Reason*
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Previous Psychiatric Hospitalizations and/or Rehabilitation
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Have you previously been hospitalized with a psychiatric disorder and/or attended a rehabilitation facility?*
- Yes
- No
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Hospital/Rehab Name*
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Year*
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Do you have additional Previous Psychiatric Hospitalizations/Rehab?
- Yes
- No
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PPHR-1
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Hospital/Rehab Name*
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Year*
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Do you have additional Previous Psychiatric Hospitalizations/Rehab?
- Yes
- No
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PPHR-2
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Hospital/Rehab Name*
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Year*
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Do you have additional Previous Psychiatric Hospitalizations/Rehab?
- Yes
- No
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PPHR-3
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Hospital/Rehab Name*
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Year*
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Do you have additional Previous Psychiatric Hospitalizations/Rehab?
- Yes
- No
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PPHR-4
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Hospital/Rehab Name*
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Year*
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Previous Psychiatric/Sleep Medications
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Have you previously been prescribed any Psychiatric/Sleep Medications?*
- Yes
- No
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Medications Name*
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Dose*
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Start Date *
MM slash DD slash YYYY
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End Date *
MM slash DD slash YYYY
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Side Effects*
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Do you have additional Medication?*
- Yes
- No
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PPSMM-2
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Medications Name*
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Dose*
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Start Date *
MM slash DD slash YYYY
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End Date *
MM slash DD slash YYYY
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Side Effects*
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Do you have additional Medication?*
- Yes
- No
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PPSMM-3
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Medications Name*
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Dose*
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Start Date *
MM slash DD slash YYYY
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End Date *
MM slash DD slash YYYY
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Side Effects*
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Do you have additional Medication?*
- Yes
- No
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PPSMM-4
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Medications Name*
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Dose*
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Start Date *
MM slash DD slash YYYY
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End Date *
MM slash DD slash YYYY
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Side Effects*
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Do you have additional Medication?*
- Yes
- No
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PPSMM-5
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Medications Name*
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Dose*
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Start Date *
MM slash DD slash YYYY
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End Date *
MM slash DD slash YYYY
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Side Effects*
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Do you have additional Medication?*
- Yes
- No
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PPSMM-6
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Medications Name*
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Dose*
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Start Date *
MM slash DD slash YYYY
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End Date *
MM slash DD slash YYYY
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Side Effects*
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Do you have additional Medication?*
- Yes
- No
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PPSMM-7
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Medications Name*
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Dose*
Start Date *
MM slash DD slash YYYY
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End Date *
MM slash DD slash YYYY
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Side Effects*
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Medication Allergies
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Do you have any Medication Allergies?*
- Yes
- No
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Name*
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Reaction*
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Do you have an additional Medication Allergies?*
- Yes
- No
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MA-2
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Name*
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Reaction*
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Pharmacy
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Do you have a Pharmacy?*
- Yes
- No
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Name*
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City*
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State*
State
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Phone #*
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Do you have an Additional Pharmacy?*
- Yes
- No
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Pharmacy-2
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Name *
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City *
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State *
State
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Phone #*
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Self Medical History
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Do you have medical history (seizures disorders, diabetes, heart problems, other)?*
- Yes
- No
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Diagnosis*
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Year Diagnosed*
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Treating Provider*
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Do you have additional medical history?*
- Yes
- No
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SMH-2
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Diagnosis*
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Year Diagnosed*
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Treating Provider*
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Do you have additional medical history?*
- Yes
- No
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SMH-3
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Diagnosis*
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Year Diagnosed*
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Treating Provider*
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Do you have additional medical history?*
- Yes
- No
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SMH-4
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Diagnosis*
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Year Diagnosed*
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Treating Provider*
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Do you have additional medical history?*
- Yes
- No
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SMH-5
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Diagnosis*
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Year Diagnosed*
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Treating Provider*
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Do you have additional medical history?*
- Yes
- No
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SMH-6
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Diagnosis*
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Year Diagnosed*
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Treating Provider*
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Physical Pain
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Have you had physical pain in the last week?*
- Yes
- No
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On this scale how bad was your pain? (0 is none and 10 is severe)*
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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Do you currenty have physical pain now?*
- Yes
- No
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On this scale how bad was your pain? (0 is none and 10 is severe)*
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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Nutritional Status
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1. Do you have food allergies?*
- Yes
- No
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2. Have you had weight loss or gain of 10 pounds or more in the last 3 months?*
- Yes
- No
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3. Have you had a decrease in food intake and/or appetite?*
- Yes
- No
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4. Do you have dental problems?*
- Yes
- No
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5. Do you have eating habits or behaviors that may be indicators of an eating disorder, such as binging or inducing vomiting?*
- Yes
- No
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What are they?*
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Nutritional Status Score Is (this field is to be hidden)
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You are identified as
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You are identified as
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You are identified as
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You are identified as
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You are identified as
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You are identified as
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Self Psychiatric History
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Do you have psychiatric history?*
- Yes
- No
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This field is hidden when viewing the form
Diagnosis*
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Year Diagnosed*
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Treating Provider*
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Do you have additional psychiatric history?*
- Yes
- No
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SPH-2
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Diagnosis*
This field is hidden when viewing the form
Year Diagnosed*
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Treating Provider*
This field is hidden when viewing the form
Do you have additional psychiatric history?*
- Yes
- No
This field is hidden when viewing the form
SPH-3
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Diagnosis*
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Year Diagnosed*
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Treating Provider*
This field is hidden when viewing the form
Do you have additional psychiatric history?*
- Yes
- No
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SPH-4
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Diagnosis*
This field is hidden when viewing the form
Year Diagnosed*
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Treating Provider*
This field is hidden when viewing the form
Do you have additional psychiatric history?*
- Yes
- No
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SPH-5
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Diagnosis*
This field is hidden when viewing the form
Year Diagnosed*
This field is hidden when viewing the form
Treating Provider*
This field is hidden when viewing the form
Do you have additional psychiatric history?*
- Yes
- No
This field is hidden when viewing the form
SPH-6
This field is hidden when viewing the form
Diagnosis*
This field is hidden when viewing the form
Year Diagnosed*
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Treating Provider*
This field is hidden when viewing the form
This field is hidden when viewing the form
Have you ever experienced trauma?*
- Yes
- No
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What trauma have you experienced?*
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Have you ever experienced abuse?*
- Yes
- No
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What abuse have you experienced?*
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Have you ever experienced neglect?*
- Yes
- No
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What neglect have you experienced?*
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Have you ever been exploited?*
- Yes
- No
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How have you been exploited?*
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Family Medical History
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Do you have biological family members with a medical history (seizures disorders, diabetes, heart problems, other)?*
- Yes
- No
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This field is hidden when viewing the form
Relationship*
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Living/Passed*
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Age*
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Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?*
- Yes
- No
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FMH-2
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Relationship*
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Living/Passed*
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?*
- Yes
- No
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FMH-3
This field is hidden when viewing the form
Relationship*
This field is hidden when viewing the form
Living/Passed*
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?*
- Yes
- No
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FMH-4
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Relationship*
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Living/Passed*
This field is hidden when viewing the form
Age*
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Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?*
- Yes
- No
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FMH-5
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Relationship*
This field is hidden when viewing the form
Living/Passed*
This field is hidden when viewing the form
Age*
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Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?*
- Yes
- No
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FMH-6
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Relationship*
This field is hidden when viewing the form
Living/Passed*
This field is hidden when viewing the form
Age*
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Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?*
- Yes
- No
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FMH-7
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Relationship*
This field is hidden when viewing the form
Living/Passed*
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?*
- Yes
- No
This field is hidden when viewing the form
FMH-8
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Relationship*
This field is hidden when viewing the form
Living/Passed*
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?*
- Yes
- No
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FMH-9
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Relationship*
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Living/Passed*
This field is hidden when viewing the form
Age*
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Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?*
- Yes
- No
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FMH-10
This field is hidden when viewing the form
Relationship*
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Living/Passed*
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Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Family Psychiatric History
This field is hidden when viewing the form
Do you have any biological family members with psychiatric history?*
- Yes
- No
This field is hidden when viewing the form
This field is hidden when viewing the form
Relationship*
This field is hidden when viewing the form
Living/Passed*
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?*
- Yes
- No
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FPH-2
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Relationship*
This field is hidden when viewing the form
Living/Passed*
This field is hidden when viewing the form
Age*
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Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?*
- Yes
- No
This field is hidden when viewing the form
FPH-3
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Relationship*
This field is hidden when viewing the form
Living/Passed*
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?*
- Yes
- No
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FPH-4
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Relationship*
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Living/Passed*
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?*
- Yes
- No
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FPH-5
This field is hidden when viewing the form
Relationship*
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Living/Passed*
This field is hidden when viewing the form
Age*
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Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?*
- Yes
- No
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FPH-6
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Relationship*
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Living/Passed*
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Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?*
- Yes
- No
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FPH-7
This field is hidden when viewing the form
Relationship*
This field is hidden when viewing the form
Living/Passed*
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?*
- Yes
- No
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FPH-8
This field is hidden when viewing the form
Relationship*
This field is hidden when viewing the form
Living/Passed*
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?*
- Yes
- No
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FPH-9
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Relationship*
This field is hidden when viewing the form
Living/Passed*
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?*
- Yes
- No
This field is hidden when viewing the form
FPH-10
This field is hidden when viewing the form
Relationship*
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Living/Passed*
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Age*
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Psychiatric History*
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Past Surgical History
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Have you had any surgeries in the past?*
- Yes
- No
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This field is hidden when viewing the form
Procedure*
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Date Of Procedure
MM slash DD slash YYYY
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Provider Name*
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Do you have an Additional Past Surgical History?*
- Yes
- No
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PSH-2
This field is hidden when viewing the form
Procedure*
This field is hidden when viewing the form
Date Of Procedure
MM slash DD slash YYYY
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Provider Name*
This field is hidden when viewing the form
Do you have an Additional Past Surgical History?*
- Yes
- No
This field is hidden when viewing the form
PSH-3
This field is hidden when viewing the form
Procedure*
This field is hidden when viewing the form
Date Of Procedure
MM slash DD slash YYYY
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Provider Name*
This field is hidden when viewing the form
Do you have an Additional Past Surgical History?*
- Yes
- No
This field is hidden when viewing the form
PSH-4
This field is hidden when viewing the form
Procedure*
This field is hidden when viewing the form
Date Of Procedure
MM slash DD slash YYYY
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Provider Name*
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Legal History
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Do you have a Current or Previous Conviction?*
- Yes
- No
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This field is hidden when viewing the form
Arrest Date
MM slash DD slash YYYY
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Charge*
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Convicted*
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Sentence*
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Do you have an Additional Legal History?*
- Yes
- No
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LH-2
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Arrest Date
MM slash DD slash YYYY
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Charge*
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Convicted*
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Sentence*
This field is hidden when viewing the form
Do you have an Additional Legal History?*
- Yes
- No
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LH-3
This field is hidden when viewing the form
Arrest Date
MM slash DD slash YYYY
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Charge*
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Convicted*
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Sentence*
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Probation
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Are you currently on Probation?*
- Yes
- No
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This field is hidden when viewing the form
Parole?*
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Ending Date?
MM slash DD slash YYYY
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Lawsuits
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Are you involved in any lawsuits?*
- Yes
- No
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Court Dates
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Do you have any upcoming Court Dates?*
- Yes
- No
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Reason
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Military Service
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Do you have a Military Service?*
- Yes
- No
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What did you do?*
- Army
- Navy
- Marines
- Coast Guard
- Air Force
- Guard
- Reserves
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Type*
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How long did you serve?
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Was your Discharge Honorable or Dishonorable?*
- Honorable
- Dishonorable
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Please explain*
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Were you involved in a any combat?*
- Yes
- No
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Please describe Combat experience*
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Are you troubled now by your military experience?*
- Yes
- No
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Please describe your trouble by military experience*
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Previous Substance Abuse
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Were you involved in Substance Abuse?*
- Yes
- No
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This field is hidden when viewing the form
Name of Substance*
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What age started using*
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What age stopped using*
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Do you have an additional Substance Abuse?*
- Yes
- No
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PSA-2
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Name of Substance*
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What age started using*
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What age stopped using*
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Do you have an additional Substance Abuse?*
- Yes
- No
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PSA-3
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Name of Substance*
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What age started using*
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What age stopped using*
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Current Substance Abuse
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Are you currently involved in Substance Abuse?*
- Yes
- No
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This field is hidden when viewing the form
Name of Substance*
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Age started?*
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Quantity*
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Do you have an additional Substance Abuse?*
- Yes
- No
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CSA-2
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Name of Substance*
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Age started?*
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Quantity*
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Do you have an additional Substance Abuse?*
- Yes
- No
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CSA-3
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Name of Substance*
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Age started?*
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Quantity*
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Nicotine
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Do you use nicotine products?*
- Yes
- No
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This field is hidden when viewing the form
What type of nicotine products do you use?*
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Other*
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This field is hidden when viewing the form
What age started using*
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What age stopped using*
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Frequency*
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Do you use any other nicotine products?*
- Yes
- No
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N-2
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What type of nicotine products do you use?*
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Other*
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This field is hidden when viewing the form
What age started using*
This field is hidden when viewing the form
What age stopped using*
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Frequency*
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Do you use any other nicotine products?*
- Yes
- No
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N-3
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What type of nicotine products do you use?*
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Other*
This field is hidden when viewing the form
This field is hidden when viewing the form
What age started using*
This field is hidden when viewing the form
What age stopped using*
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Frequency*
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Do you use any other nicotine products?*
- Yes
- No
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N-4
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What type of nicotine products do you use?*
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Other*
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This field is hidden when viewing the form
What age started using*
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What age stopped using
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Frequency*
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Vape
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Do you Vape?*
- Yes
- No
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Drink
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Do you drink alcohol?*
- Yes
- No
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Alcohol Screening Questionnaire ( AUDIT )
Our clinic asks all patients about alcohol use at least once a year. Drinking alcohol can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below.
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1. How often do you have a drink containing alcohol?*
- Never
- Monthly or Less
- 2-4 Times a Month
- 2-3 Times a Week
- 4 or more Times a Week
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2. How many drinks containing alcohol do you have on a typical day when you are drinking?*
- 0-2
- 3 or 4
- 5 or 6
- 7 - 9
- 10 or more
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3. How often do you have four or more drinks on one occasion*
- Never
- Less than monthly
- Monthly
- Weekly
- Daily or almost daily
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4. How often during the last year have you found that you were not able to stop drinking once you had started?*
- Never
- Less than monthly
- Monthly
- Weekly
- Daily or almost daily
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5. How often during the last year have you failed to do what was normally expected of you because of drinking?*
- Never
- Less than monthly
- Monthly
- Weekly
- Daily or almost daily
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6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?*
- Never
- Less than monthly
- Monthly
- Weekly
- Daily or almost daily
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7. How often during the last year have you had a feeling of guilt or remorse after drinking?*
- Never
- Less than monthly
- Monthly
- Weekly
- Daily or almost daily
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8. How often during the last year have you been unable to remember what happened the night before because of your drinking?*
- Never
- Less than monthly
- Monthly
- Weekly
- Daily or almost daily
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9. Have you or someone else been injured because of your drinking?*
- No
- Yes, but not in the last year
- Yes, in the last year
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10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?*
- No
- Yes, but not in the last year
- Yes, in the last year
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What age started using*
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What age stopped using
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Are you currently, or have you previously received treatment for an alcohol problem?*
- Yes
- No
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This field is hidden when viewing the form
Have you ever been in treatment for an alcohol problem?*
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Currently
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At what location?*
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Frequency of visit*
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When was the last time you had an alcoholic drink?*
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In the past
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At what location?*
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What year?
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When was the last time you had an alcoholic drink?*
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Social History/Marital Status
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Marital Status*
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Social History/Sexual Orientation
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Sexual Orientation*
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Gender
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Gender*
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Education
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Have you completed your education?*
- Yes
- No
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This field is hidden when viewing the form
Highest Schooling*
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Employment
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Are you Employed?*
- Yes
- No
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This field is hidden when viewing the form
Type of Employment
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Company Name
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Occupation*
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This field is hidden when viewing the form
Not-Employed*
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Physical Exam Self Assessment
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Please rate your Thought Process*
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Please rate your Long Term Memory*
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Please rate your Short Term Memory*
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Please rate your Concentration*
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Current Stressors
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Do you have Current Stressors?*
- Yes
- No
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Please choose them below:*
- Conflict with Children
- Conflict with Family
- Conflict with Siblings
- Emotional
- Financial Problems
- Health Problems
- Housing Problems
- Job Loss or Change
- Legal Problems
- Physical
- Poor Peer Relations
- Problems at Work
- Recent Death
- Recent Move
- Separation/Divorce
- Sexual
- Victim of Abuse
- Other
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Other
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Select the symptoms you are experiencing*
- Aggression/Anger Outburst
- Anxiety
- Alcohol/Drug Abuse
- Avoidance of People
- Chest Pains
- Computer Addiction
- Depression
- Difficulty Thinking
- Difficulty Concentrating
- Dizziness
- Distractibility
- Eating Disorder
- Elevated Mood
- Excessive Crying
- Excessive Laughing
- Hallucinations
- Helplessness
- Impulsivity
- Irritability
- Memory Problems
- Muscle Tension
- Racing Thoughts
- Sexual Addiction
- Sleeping Problems
- Stressed Out
- Suicidal Thoughts
- Weight Gain/Loss
- Worrying
- Fatigue
- Gambling
- Headaches
- Hopelessness
- Indecisiveness
- Loneliness
- Mood Swings
- Panic Attacks
- Restless/On Edge
- Sexual Difficulties
- Snoring
- Stop Breathing
- Trembling
- Withdrawn
- Worthlessness
- Other
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Other
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Hallucinations
Hallucinations are defined as sight, sound, smell, taste, or touch that a person believes to be real but is not real. Hallucinations can be caused by nervous system disease, certain drugs, or mental disorders.
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Do you have hallucinations?*
- Yes
- No
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This field is hidden when viewing the form
What type of Hallucinations do you experience?*
- Audio
- Visual
- Tactile/Sensory
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Delusions
A delusion is defined as a false belief based on incorrect inference about external reality that is firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary.
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Are you Delusional?*
- Yes
- No
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Possession of Gun
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Do you own a gun?*
- Yes
- No
Meeting your needs is our top priority. If you don't receive a response from us within 24 business hours, please feel free to reach out
by calling us at 817-488-8998 ext 2 or emailing info@MidCitiesPsychiatry.com.

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New Patient

Primary Insurance

Secondary Insurance

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

Generalized Anxiety Disorder Questionnaire ( GAD-7 )

Rapid Mood Screener (RMS)

Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form (Q-LES-Q-SF)

PIF

Previous Psychiatric Diagnosis

Previous Psychiatric Hospitalizations and/or Rehabilitation

Previous Psychiatric/Sleep Medications

Medication Allergies

Pharmacy

Self Medical History

Physical Pain

Nutritional Status

Self Psychiatric History

Family Medical History

Family Psychiatric History

Past Surgical History

Legal History

Probation

Lawsuits

Court Dates

Military Service

Previous Substance Abuse

Current Substance Abuse

Nicotine

Vape

Drink

Alcohol Screening Questionnaire ( AUDIT )

Currently

In the past

Social History/Marital Status

Social History/Sexual Orientation

Gender

Education

Employment

Physical Exam Self Assessment

Current Stressors

Hallucinations