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Date
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Date Submitted
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What is your MRN?*
Demographics Patient's Last Name*
Email*
Date of Birth* This field is hidden when viewing the form
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Age*
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Do you have a new phone #?* New Phone #
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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 JPG or PDF format. Please provide the back image of your Driver's License in JPG or PDF format.
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Appointment Date*
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Height (feet/inches)*
For better patient care, please complete the information below. Weight (pounds)
Temperature (Fahrenheit)
Blood Pressure
Pulse Rate (BPM)
Reason for visit*
Insurance Information Do you have a New Insurance?* Please provide the front image of your Insurance Card in JPG or PDF format. Please provide the back image of your Insurance Card in JPG or PDF 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. Do you have a New Secondary Insurance?* 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
Secondary Insurance ID #
Secondary Insurance Group #
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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 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
Button RCN* This field is hidden when viewing the form
Date of Birth*
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Have there been any changes to your personal information since your last visit?* Please only fill the following information if you have had a change in any of your information since your last visit: This field is hidden when viewing the form
Home Phone Number
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Work Phone Number
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Primary Insurance Name
Do you have Secondary Insurance* Secondary Insurance Name
Please provide a copy of the front image of your Secondary Insurance Card if you have received a new one. Please provide a copy of the back image of your Secondary Insurance Card if you have received a new one. Do you have Tertiary Insurance* Tertiary Insurance Name
Please provide a copy of the front image of your Tertiary Insurance Card if you have received a new one. Please provide a copy of the back image of your Tertiary Primary Insurance Card if you have received a new one. This field is hidden when viewing the form
Do you have a New Insurance?* Please provide a copy of your Insurance Card if you have received a new one. Are you a Medicare Patient?* Please provide a copy of the front image of your Primary Insurance Card if you have received a new one. Please provide the front image of your Insurance ID in JPG or PDF format. Please provide the back image of your Insurance ID in JPG or PDF format.
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Do you have a new email?* This field is hidden when viewing the form
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Do you have any changes in Medication?* This field is hidden when viewing the form
Do you have any changes in Medication? (YES) This field is hidden when viewing the form
Medications Name*
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Dose*
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Start Date*
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End Date*
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Side Effects*
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Do you have an additional Medication Changes?* This field is hidden when viewing the form
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Medications Name*
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Dose*
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Start Date*
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End Date*
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Side Effects*
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Do you have an additional Medication Changes?* This field is hidden when viewing the form
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Medications Name*
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Dose*
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Start Date*
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End Date*
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Side Effects*
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RCN 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 Not Applicable Bad Same Better
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How do you feel since you began this treatment?* Choose your answer Not Applicable Bad Same Better
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Physical Health - Your Current State This field is hidden when viewing the form
Dependent Care Resources Dependent Care Resources This field is hidden when viewing the form
Do you need resources for the care of your dependents?* This field is hidden when viewing the form
Psychiatric Advance Directive Question: Psychiatric Advance Directive This field is hidden when viewing the form
Do you have a Psychiatric Advance Directive?* This field is hidden when viewing the form
Please provide your Psychiatric Advanced Directive in PDF format. This field is hidden when viewing the form
Would you like to create one?* This field is hidden when viewing the form
Legal Need Resources Legal Need Resources This field is hidden when viewing the form
Are you in need of legal assistance or support?* This field is hidden when viewing the form
Vocational Need Resources Question Vocational Need Resources This field is hidden when viewing the form
Do you need vocational assistance or support?* This field is hidden when viewing the form
Current Mental Health Care Providers This field is hidden when viewing the form
Do you have a Psychotherapist?* This field is hidden when viewing the form
Since your last visit, is your current Psychotherapist the same or a new one?* 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*
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Date of last visit*
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Do you have a Psychologist?* This field is hidden when viewing the form
Do you have a Psychologist?* This field is hidden when viewing the form
Since your last visit, your current Psychologist same or a new one?* 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*
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Date of last visit*
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Current Stressors This field is hidden when viewing the form
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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What type of appointment do you have* Choose Your Provider* 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* 2. Feeling down, depressed, or hopeless* 3. Trouble falling or staying asleep, or sleeping too much* 4. Feeling tired or having little energy* 5. Poor appetite or overeating* 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down* 7. Trouble concentrating on things, such as reading the newspaper or watching television* 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* 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
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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02If 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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03If 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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04If 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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05If 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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06If 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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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.
Would you like our patient navigator advocate to contact you to assist you in the treatment option? Please indicate your preference:* Suicidal Ideations In the past month
Have you wished you were dead or wished you could go to sleep and not wake up?* Suicidal Ideations In the past month
Have you wished you were dead or wished you could go to sleep and not wake up?* This field is hidden when viewing the form
Have you actually had any thoughts of killing yourself?* Have you been thinking about how you might do this?* Have you had these thoughts and had some intention of acting on them?* Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?* Have you ever done anything, started to do anything, or prepared to do anything to end your life?* Was this within the past three months?* 001Suicidal Ideations TMS In the past month
010Have you wished you were dead or wished you could go to sleep and not wake up?* 020Have you actually had any thoughts of killing yourself?* 030Have you been thinking about how you might do this?* 040Have you had these thoughts and had some intention of acting on them?* 050Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?* 060Have you ever done anything, started to do anything, or prepared to do anything to end your life?* 070Was this within the past three months? TMS* This field is hidden when viewing the form
Patients categorized as
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Provider
Transportation Do you have a ride today to take you home after treatment?* Homicidal Ideations Are you having thoughts of harming other people?* Homicidal Ideations Are you having thoughts of harming other people?* Homicidal Ideations Are you having thoughts of harming other people?* This field is hidden when viewing the form
Do You Have a Plan?* What is your plan?*
Possession of Gun Do you own a gun?* 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?* 2. Not being able to stop or control worrying?* 3. Worrying too much about different things?* 4. Trouble relaxing?* 5. Being so restless that it is hard to sit still?* 6. Becoming easily annoyed or irritable?* 7. Feeling afraid as if something awful might happen?* Your GAD Scale Total Score Is
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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. 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*
Current Providers Primary Care Provider Have you already told us about your Primary Care Physician?* Do you have a Primary Care Physician?* Who is 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
Do you need help finding a Primary Care Provider?* Psychotherapist Have you already told us about your Psychotherapist?* This field is hidden when viewing the form
Psychotherapist This field is hidden when viewing the form
Have you already told us about your Psychotherapist?* This field is hidden when viewing the form
Do you have a Psychotherapist?* Who is your Psychotherapist?*
When was your last visit to your Psychotherapist?
MM slash DD slash YYYY
Would you be interested in exploring Psychotherapy services at Mid Cities Psychiatry?* Psychologist Have you already told us about your Psychologist?* Do you have a Psychologist?* Who is your Psychologist?*
When was your last visit to your Psychologist?
MM slash DD slash YYYY
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Would you be interested in exploring Psychology services at Mid Cities Psychiatry?* This field is hidden when viewing the form
Stressors Current Medical State Stressors Do you have Current Stressors?* Stressors 02Do you have Current Stressors?* Stressors 03Do you have Current Stressors?* This field is hidden when viewing the form
If yes, please describe:
Symptoms Do you have Current Symptoms?* If yes, please describe:
Physical Pain Have you had physical pain in the last week?* On this scale how bad was your pain? Select 0 1 2 3 4 5 6 7 8 9 10
Do you have physical pain now?* On this scale how bad was your pain? Select 0 1 2 3 4 5 6 7 8 9 10
Nutritional Status Do you have food allergies?* Have you had weight loss or gain of 10 pounds or more in the last 3 months?* Have you had a decrease in food intake and/or appetite?* Do you have dental problems?* Do you have eating habits or behaviors that may be indicators of an eating disorder, such as binging or inducing vomiting?* What are they?
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Nutritional Status Score Is (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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You are identified as
Current Psychiatric Health - Progress Esketamine How have you felt since your previous visit?* Please Explain:
How long has the relief lasted?
Have you noticed any side effects?
06What concerns do you have about treatment?
Current Psychiatric Health - Progress (TMS) How have you felt since your previous visit?* Please Explain:
Have you made any progress with your depression since treatment has started?* Please Explain:
What adjustments have you made?
How long has the relief lasted?
Have you noticed any side effects?
What concerns do you have about treatment?
What is your pain level out of 10 with this treatment Select 0 1 2 3 4 5 6 7 8 9 10
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Progress Current Psychiatric Health Progress How have you felt since your previous visit?* Please Explain:
Trauma, Abuse, Neglect, and Exploitation Have you recently experienced any new trauma, abuse, neglect, or exploitation?* What did you experience? Please Explain:*
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What trauma have you experienced?*
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Have you ever experienced trauma?* This field is hidden when viewing the form
What trauma have you experienced?*
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Have you ever experienced abuse?* This field is hidden when viewing the form
What abuse have you experienced?*
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Have you ever experienced neglect?* This field is hidden when viewing the form
What neglect have you experienced?*
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Have you ever been exploited?* This field is hidden when viewing the form
How have you been exploited?*
Medication History - Current Medications TMS/ Esket 04Have you had changes in your psychiatric medications and non-psychiatric medications?* 01What medication(s) have you taken today?
02What were the doses of the medication(s)?
03What side effects did you experience from the medication?
04Have you had changes in your psychiatric medications and non-psychiatric medications?* This field is hidden when viewing the form
Medication History - Psychiatric Medications Medication History Psychiatric Medications Have you had changes in your Psychiatric Medications?* What was the name of the medication?*
What was the dose of the medication?*
When did you start taking the medication?*
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When did you stop taking the medication?
MM slash DD slash YYYY
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Side effects?*
Have you had additional changes in your Psychiatric Medications?* What was the name of the medication?*
What was the dose of the medication?*
When did you start taking the medication?*
MM slash DD slash YYYY
When did you stop taking the medication?
MM slash DD slash YYYY
Side effects?*
Have you had additional changes in your Psychiatric Medications?* What was the name of the medication?*
What was the dose of the medication?*
When did you start taking the medication?*
MM slash DD slash YYYY
When did you stop taking the medication?
MM slash DD slash YYYY
Side effects?*
Have you had additional changes in your Psychiatric Medications?* What was the name of the medication?*
What was the dose of the medication?*
When did you start taking the medication?*
MM slash DD slash YYYY
When did you stop taking the medication?
MM slash DD slash YYYY
Side effects?*
Have you had additional changes in your Psychiatric Medications?* What was the name of the medication?*
What was the dose of the medication?*
When did you start taking the medication?*
MM slash DD slash YYYY
When did you stop taking the medication?
MM slash DD slash YYYY
Side effects?*
Non-Psychiatric Medications Have you had changes in your Non-Psychiatric Medications?* What was the name of the medication?*
What was the dose of the medication?*
When did you start taking the medication?*
MM slash DD slash YYYY
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When did you stop taking the medication?
MM slash DD slash YYYY
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Side effects?*
Have you had additional changes in your Non-Psychiatric Medications?* What was the name of the medication?*
What was the dose of the medication?*
When did you start taking the medication?*
MM slash DD slash YYYY
When did you stop taking the medication?
MM slash DD slash YYYY
Side effects?*
Have you had additional changes in your Non-Psychiatric Medications?* What was the name of the medication?*
What was the dose of the medication?*
When did you start taking the medication?*
MM slash DD slash YYYY
When did you stop taking the medication?
MM slash DD slash YYYY
Side effects?*
Have you had additional changes in your Non-Psychiatric Medications?* What was the name of the medication?*
What was the dose of the medication?*
When did you start taking the medication?*
MM slash DD slash YYYY
When did you stop taking the medication?
MM slash DD slash YYYY
Side effects?*
Have you had additional changes in your Non-Psychiatric Medications?* What was the name of the medication?*
What was the dose of the medication?*
When did you start taking the medication?*
MM slash DD slash YYYY
When did you stop taking the medication?
MM slash DD slash YYYY
Side effects?*
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