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200 Westpark Way, Euless, TX 76040

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Scheduled Appointment Intake Form

Mid Cities Psychiatry
Scheduled Appointment Intake Form

To ensure the best possible service, please complete the form in its entirety and click submit at the end to help us understand your needs and provide you with holistic care.
The form takes 5-10 minutes to complete. If you can’t complete it electronically, please call us 817-488-8998 ext 2 or e-mail us at info@MidCitiesPsychiatry.com to assist you.

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Date
MM slash DD slash YYYY
Patient's Last Name*
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Date of Birth*
MM slash DD slash YYYY
Date of Birth*
Month
Day
Year
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Age*
We apologize for the inconvenience, we only see patients 16 years of age or older.
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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 Chiu, MPAS, PA-C
Appointment Date*
MM slash DD slash YYYY
Time
Hours :
Minutes
AM/PM
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Do you have a new phone #?*
- Yes
- No
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New Phone #*
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Do you have a new email?*
- Yes
- No
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New Email*
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Have you moved?*
- Yes
- No
New Address
Street Address*
City*
State*
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.
Accepted file types: pdf, jpg, Max. file size: 120 MB.
Please provide the back image of your Driver's License in JPG or PDF format.
Accepted file types: pdf, jpg, Max. file size: 120 MB.
Please Note: There may be a slight delay of 1-2 minutes in processing your attachments based on their sizes. You're requested only to attach them once and wait for them to load.
Your understanding is greatly appreciated.
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Do you have any changes in Medication?*
- Yes
- No
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Do you have any changes in Medication? (YES)
Medications Name*
Dose*
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Side Effects*
Do you have an additional Medication Changes?*
- Yes
- No
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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?*
- Yes
- No
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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?*
- Yes
- No
Please upload if you have a new Insurance card
Please provide the front image of your Insurance Card in JPG or PDF format.
Accepted file types: pdf, jpg, Max. file size: 120 MB.
Please provide the back image of your Insurance Card in JPG or PDF format.
Accepted file types: pdf, jpg, Max. file size: 120 MB.
Please Note: There may be a slight delay of 1-2 minutes in processing your attachments based on their sizes. You're requested only to attach them once and wait for them to load.
Your understanding is greatly appreciated.
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Do you have a New Secondary Insurance?*
- Yes
- No
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Secondary Insurance*
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Secondary Insurance ID #
Secondary Insurance Group #
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I understand that Mid Cities Psychiatry may request a Urine Drug Screen, which I must provide either at Mid Cities Psychiatry's office or at an accredited laboratory within 48 hours of their request. If the screen detects substances not prescribed (including THC, Delta 8, Kratom, and Alcohol) or if it shows a lack of prescribed medications, Mid Cities Psychiatry reserves the right to decline any further prescriptions.*
- I Agree (Mandatory)
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RCN
I acknowledge that Mid Cities Psychiatry has an appointment reschedule, cancellation, and no-show policy. This policy requires me to contact Mid Cities Psychiatry 24 business hours prior to my appointment in order to reschedule or cancel it. Weekends, long weekends, or national holidays do not apply as business hours, since the office is closed. Otherwise, Mid Cities Psychiatry has the right to charge me for a missed appointment according to the RCN Fee Schedule below.
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
    • 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)
Psychiatric Health - Your Current State
How have you felt since your previous visit?*
How do you feel since you began this treatment?*
Height (feet/inches)
Weight (pounds)*
Blood Pressure*
Pulse Rate (BPM)*
Temperature (Fahrenheit)
Are you having thoughts of harming yourself?*
- Yes
- Yes and I am afraid I may act on them
- No
Are you having thoughts of harming other people?*
- Yes
- Yes and I am afraid I may act on them
- No
Current Stressors
Current Stressors
- 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
Other
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
Other
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*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
2. Feeling down, depressed, or hopeless*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
3. Trouble falling or staying asleep, or sleeping too much*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
4. Feeling tired or having little energy*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
5. Poor appetite or overeating*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
7. Trouble concentrating on things, such as reading the newspaper or watching television*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
9. Thoughts that you would be better off dead or of hurting yourself in some way*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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Not At All
Several Days
More Than Half of the Days
Nearly Every Day
Your PHQ-9 Scale Total Score Is
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?*
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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.
    • SPRAVATO™ (Esketamine) Nasal Spray used in conjunction with oral antidepressants for treatment-resistant depression.
    • Ketamine is an innovative approach showing promising results quickly alleviating symptoms of depression and anxiety.
Would you like our patient advocate to contact you to assist you in the treatment option? Please indicate your preference:*
- TMS Therapy
- SPRAVATO™
- Ketamine
- Would Like To Know Best Treatment Option
- None
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Do you have a Psychotherapist?*
- Yes
- No
Since your last visit, is your current Psychotherapist the same or a new one?*
- Same
- New
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Name*
Email*
Phone Number*
Fax Number*
City*
State*
State
Date of last visit*
MM slash DD slash YYYY
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Date of last visit*
MM slash DD slash YYYY
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Do you have a Psychologist?*
- Yes
- No
Do you have a Psychologist?*
- Yes
- No
Since your last visit, your current Psychologist same or a new one?*
- Same
- New
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Name*
Email*
Phone Number*
Fax Number*
City*
State*
State
Date of last visit*
MM slash DD slash YYYY
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Date of last visit*
MM slash DD slash YYYY
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?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
2. Not being able to stop or control worrying?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
3. Worrying too much about different things?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
4. Trouble relaxing?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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
6. Becoming easily annoyed or irritable?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
7. Feeling afraid as if something awful might happen?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
Your GAD Scale Total Score Is
Please Note; processing your form may take 1-2 minutes. To avoid delays, kindly press the submit button only once and wait for the thank you message.
We appreciate your patience.
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?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
2. Not being able to stop or control worrying?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
3. Worrying too much about different things?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
4. Trouble relaxing?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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
6. Becoming easily annoyed or irritable?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
7. Feeling afraid as if something awful might happen?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
Your GAD Scale Total Score Is*
Subject to your insurance eligibility (if you have insurance), our appointment team
will call you ASAP to schedule an appointment for you on the next available appointment slot.
Please note that we cannot guarantee the requested appointment date. Our dedicated Appointment Team
will contact you to schedule an appointment. This is subject to your insurance eligibility. Rest assured, your needs are important to us.
If you don't hear from us within 24 business hours, please contact us at 817-488-8998 ext 2 or e-mail us at info@MidCitiesPsychiatry.com.

Δ

PLEASE Go To Your Nearest Emergency Room or Call 911.

Contact Us!

200 Westpark Way, Euless, TX 76040

(817) 488-8998

(855) 295-2686

Monday – Friday, 8 am-5 pm

1323 E Franklin Street, #102 Hillsboro, TX 76645

(254) 266-6262

(855) 295-2686

Monday – Friday, 8 am-5 pm

About Mid Cities Psychiatry

Mid Cities Psychiatry specializes in the diagnosis, treatment and mental health issues, including substance use disorders. We are qualified to assess both the mental and physical aspects of psychological disturbance.

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