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Date
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Are You An Existing Patient?* This field is hidden when viewing the form
What is your MRN?
Patient's Last Name*
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Date of Birth*
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Date of Birth* This field is hidden when viewing the form
Age*
We apologize for the inconvenience, we only see patients 16 years of age or older. This field is hidden when viewing the form
Do you have a new phone #?* This field is hidden when viewing the form
New Phone #*
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Same Phone #*
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Do you have a new email?* This field is hidden when viewing the form
New Email*
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Have you moved?* New Address Street Address*
City*
State*
Zip/Postal Code*
Please upload if you have a new Driver's License Please provide the front image of your Driver's License in PDF or JPG format. Please provide the back image of your Driver's License in PDF or JPG format.
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. This field is hidden when viewing the form
Do you have any changes in Medication?* This field is hidden when viewing the form
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?* This field is hidden when viewing the form
MDC-2 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?* This field is hidden when viewing the form
MDC-3 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 Insurance?* Please upload if you have a new Insurance card Please provide the front image of your Insurance Card in PDF or JPG format.* Please provide the back image of your Insurance Card in PDF or JPG format.*
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. This field is hidden when viewing the form
Do you have a New Secondary Insurance?* This field is hidden when viewing the form
Secondary Insurance* Select Optional Aetna Allsaver Ambetter From Superior Health Plan American Behavioral Health Blue Cross Blue Shield Care Improvement Plan Care N Care Cigna CompSych GHI - BMP Golden Rule Group and Pension Administrator(GPA) HealthScope HealthSmart (Network) Humana Magellan Behavioral Health Medicare Molina Texas Healthcare Mulitiplan (Network) Mutual of Omaha Medicare Advantage Plan New Era Life Insurance PHCS (Network) Scott & White Health Plan Silver Back TPA Tricare East Region Tricare For Life Triwest Triwest UMR United HealthCare
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Secondary Insurance ID #
Secondary Insurance Group #
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Appointment Reason* Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Esketamine (Sparavto) Mood Disorders Obsessive-Compulsive-Disorder (OCD) Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS Other
Other
Appointment Reason Description*
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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.* This field is hidden when viewing the form
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
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.* This field is hidden when viewing the form
Psychiatric Health - Your Current State This field is hidden when viewing the form
How have you felt since your previous visit?* Choose your answer Bad Same Better
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How do you feel since you began this treatment?* Choose your answer Bad Same Better
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Are you having thoughts of harming yourself?* This field is hidden when viewing the form
Are you having thoughts of harming other people?* This field is hidden when viewing the form
Current Stressors Current Stressors This field is hidden when viewing the form
Other
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Select the symptoms you are experiencing This field is hidden when viewing the form
Other
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Patient Health Questionnaire ( PHQ-9 ) Over the last 2 weeks, how often have you been bothered by any of the following problems? Use the following scale to choose the most appropriate number for each situation: 1. Little interest or pleasure in doing things* This field is hidden when viewing the form
2. Feeling down, depressed, or hopeless* This field is hidden when viewing the form
3. Trouble falling or staying asleep, or sleeping too much* This field is hidden when viewing the form
4. Feeling tired or having little energy* This field is hidden when viewing the form
5. Poor appetite or overeating* This field is hidden when viewing the form
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down* This field is hidden when viewing the form
7. Trouble concentrating on things, such as reading the newspaper or watching television* This field is hidden when viewing the form
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual* This field is hidden when viewing the form
9. Thoughts that you would be better off dead or of hurting yourself in some way* This field is hidden when viewing the form
Not At All
Several Days
More Than Half of the Days
Nearly Every Day
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Your PHQ-9 Scale Total Score Is
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If you checked off any of the problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? * Select Option Not difficult at all Somewhat difficult Very difficult Extremely difficult
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If you checked off any of the problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? * Select Option Not difficult at all Somewhat difficult Very difficult Extremely difficult
Based on your responses, Mid Cities Psychiatry provides various treatment alternatives. These include:
• TMS (Transcranial Magnetic Stimulation) is a non-invasive therapy alternative for treatment-resistant depression.
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Would you like our patient advocate to contact you to assist you in the treatment option? Please indicate your preference: * This field is hidden when viewing the form
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Do you have a Psychotherapist?* This field is hidden when viewing the form
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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*
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Date of last visit*
MM slash DD slash YYYY
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Do you have a Psychologist?* This field is hidden when viewing the form
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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*
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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. This field is hidden when viewing the form
Would you like to be contacted by a patient advocate to know more about TMS Therapy?* This field is hidden when viewing the form
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. 1. Feeling nervous, anxious or on edge?* This field is hidden when viewing the form
2. Not being able to stop or control worrying?* This field is hidden when viewing the form
3. Worrying too much about different things?* This field is hidden when viewing the form
4. Trouble relaxing?* This field is hidden when viewing the form
5. Being so restless that it is hard to sit still?* This field is hidden when viewing the form
6. Becoming easily annoyed or irritable?* This field is hidden when viewing the form
7. Feeling afraid as if something awful might happen?* This field is hidden when viewing the form
Your GAD Scale Total 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. * Please make sure to submit your previous Connors (ADHD) Testing or Personality Assessment Inventory results soon after your appointment is scheduled
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Are you interested in learning more about Connors (ADHD) Testing or Personality Assessment Inventory Testing? * This field is hidden when viewing the form
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. This field is hidden when viewing the form
1. Feeling nervous, anxious or on edge?* This field is hidden when viewing the form
2. Not being able to stop or control worrying?* This field is hidden when viewing the form
3. Worrying too much about different things?* This field is hidden when viewing the form
4. Trouble relaxing?* This field is hidden when viewing the form
5. Being so restless that it is hard to sit still?* This field is hidden when viewing the form
6. Becoming easily annoyed or irritable?* This field is hidden when viewing the form
7. Feeling afraid as if something awful might happen?* This field is hidden when viewing the form
Your GAD Scale Total Score Is*
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Please specify your preferred future appointment date? Providers * Choose Your Provider Bailey Hofer, MSC, PA-C Brenda Broadnax, MS, LPC Debora Simpson, MA, LPC Haylee Hughes, MPAS, PA-C Heather Spengler, MSC.PMHNP-BC Jenny Bui, MMS, PA-C Nancy Sperry, MS, MA, LCSW Dr. Ramya Seeni, MD Rebecca Perthel, MMSC, PA-C Dr. Seema Kazi, MD Susana Cardenas, MSW, LCSW Wing-Kei "Kaye" Chiu, MPAS, PA-C
Appointment Date *
MM slash DD slash YYYY
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Please specify your preferred future appointment date? Providers * Choose Your Provider Bailey Hofer, MSC, PA-C Brenda Broadnax, MS, LPC Debora Simpson, MA, LPC Haylee Hughes, MPAS, PA-C Heather Spengler, MSC.PMHNP-BC Jenny Bui, MMS, PA-C Nancy Sperry, MS, MA, LCSW Dr. Ramya Seeni, MD Rebecca Perthel, MMSC, PA-C Dr. Seema Kazi, MD Susana Cardenas, MSW, LCSW Wing-Kei "Kaye" Chiu, MPAS, PA-C
Appointment Date *
MM slash DD slash YYYY
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Please specify your preferred future appointment date? Providers * Choose Your Provider Bailey Hofer, MSC, PA-C Brenda Broadnax, MS, LPC Debora Simpson, MA, LPC Haylee Hughes, MPAS, PA-C Heather Spengler, MSC.PMHNP-BC Jenny Bui, MMS, PA-C Nancy Sperry, MS, MA, LCSW Dr. Ramya Seeni, MD Rebecca Perthel, MMSC, PA-C Dr. Seema Kazi, MD Susana Cardenas, MSW, LCSW Wing-Kei "Kaye" Chiu, MPAS, PA-C
Appointment Date *
MM slash DD slash YYYY
Subject to your insurance eligibility (if you have insurance), our appointment team Please note that we cannot guarantee the requested appointment date. Our dedicated Appointment Team Please Note, processing your form may take 1-2 minutes.
only once and wait for the thank you message. 
The Best Mental Health Service Provider in Texas 