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200 Westpark Way, Euless, TX 76040

Call Us 817-488-8998 817-488-8998

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Mid Cities Psychiatry
Make An Appointment Version 2
Existing Patient

Make An Appointment!

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Are You An Existing Patient?
Patient's Last Name*
Date of Birth*
Date Format: MM slash DD slash YYYY
Age*
We apologize for the inconvenience and we only see patients 16 years of age or older.
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Phone Number*
Email*
Street Address*
City*
State*
State
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State
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Please upload if you have an updated Driver's license
Please provide the front image of your Driver's License*
Accepted file types: pdf.
Please provide the back image of your Driver's License*
Accepted file types: pdf.
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Do You Have Any Changes in Medication?*
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Medications Name*
Dose*
Start Date*
Date Format: MM slash DD slash YYYY
End Date*
Date Format: MM slash DD slash YYYY
Side Effects*
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Please upload if you have a new Insurance card
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Do You Have A Secondary New Insurance?*
- Yes
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Secondary Insurance*
Secondary Insurance ID #
Secondary Insurance Group #
Appointment Reason*
Appointment Reason Description*
Patient Health Questionnaire ( PHQ-9 )
Please select each appropriate answer in the question as to 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
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?*
Do you have a Psychotherapist?*
- Yes
- No
Name*
City*
State*
Phone Number*
Fax Number*
Email*
Date of last visit*
Date Format: MM slash DD slash YYYY
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Do you have a Psychologist?*
- Yes
- No
Name*
City*
State*
Phone Number*
Fax Number*
Email*
Date of last visit*
Date Format: MM slash DD slash YYYY
Generalized Anxiety Disorder Questionnaire ( GAD-7 )
Please select each appropriate answer in the question as to 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.) 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

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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 The 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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