Mid Cities Psychiatry’s Forms

Please know that your Forms must be completed and Mid Cities Psychiatry must have them at least 24 business hours before your appointment for HIPAA compliance and for your better care.

Please remember

  • Once your appointment is made, our appointment-team will send you an interactive Registration-Forms’ link for you to complete the forms.
  • You may also download the Registration Forms below, print them, fill them completely, and drop them off at our office at least 24 business hours before your appointment.
  • You may also come to our office to request a blank copy of the Registration Forms to be filled completely, and then to be dropped off at our office at least 24 business hours before your appointment.

If your forms are not completed before the appointment, then our provider may not be able to see you and you’ll be billed $75.00 for a no-show.

Registration Form

Download

Registration Form

Download

Consent Forms

Download

Consent Forms

Download

Registration Form - Psychologist

Download

Registration Form - Psychologist

Download

Psychiatric Prescriptions Acknowledgement

Download

Psychiatric Prescriptions Acknowledgement

Download

Referral Form

Download

Referral Form

Download

Referral Esketamine Medical Side Insurance

Download

Referral Esketamine Medical Side Insurance

Download

Referral TMS

Download

Referral TMS

Download

MedAcknowledgement (ADD)

Download

MedAcknowledgement (ADD)

Download

Patient Information

Download

Patient Information

Download

Med Acknowledgement (OPIATE MGMT)

Download

Med Acknowledgement (OPIATE MGMT)

Download

Consent Form - Patient Communication

Download

Consent Form - Patient Communication

Download

Generalized Anxiety Disorder, Alcohol Screening & PatientHealth Questionare

Download

Generalized Anxiety Disorder, Alcohol Screening & PatientHealth Questionare

Download

Scheduled Appointment Form - Psychology Evaluation

Download

Scheduled Appointment Form - Psychology Evaluation

Download

Scheduled Appointment Form - Medication Management

Download

Scheduled Appointment Form - Medication Management

Download

Scheduled Appointment Form - Therapy

Download

Scheduled Appointment Form - Therapy

Download

Pre-Authorized Payment Plan

Download

Pre-Authorized Payment Plan

Download

Telemedicine Consent Form

Download

Telemedicine Consent Form

Download

Patient Financial Policy

Download

Patient Financial Policy

Download

Reschedule, Cancellation & No-Show Policy

Download

Reschedule, Cancellation & No-Show Policy

Download