Make An Appointment! 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 Please Choose Below The Appointment TypeAppointment TypeAppointment TypeNew PatientFollow-Up or Requested An Appointment BeforeExisting PatientAre You An Existing Patient? Patient's Last Name* Last Date of Birth* Date Format: MM slash DD slash YYYY age2We apologize for the inconvenience and we only see patients 16 years of age or older.*Phone Number*Email* Please enter if you have a new address*Street AddressCity*State / Province / Region*Zip/Postal Code*My InsuranceSelect Primary InsuranceSelf-payPrimary InsurancePrimary New InsurancePlease enter if you have new insuranceAetnaAllsaverAmbetter From Superior Health PlanAmerican Behavioral HealthBlue Cross Blue ShieldBright HealthCareCare Improvement PlanCare N CareCignaCompSychGHI - BMPGolden RuleGroup and Pension Administrator(GPA)HealthScopeHealthSmart (Network)HumanaMagellan Behavioral HealthMedicareMolina Texas HealthcareMulitiplan (Network)Mutual of Omaha Medicare Advantage PlanNew Era Life InsurancePHCS (Network)Scott & White Health PlanSilver Back TPATricare East RegionTricare For LifeTriwestTriwestUMRUnited HealthCareOther InsuranceOther Insurance*Primary Insurance ID #*Primary Insurance Group #Please upload if you have a new Insurance cardPlease provide the front image of your insurance cardPlease provide the back image of your insurance cardPlease upload if you have an updated Driver's licensePlease provide the front image of your Driver's LicensePlease provide the back image of your Driver's LicenseSecondary Insurance--Select Optional--AetnaAllsaverAmbetter From Superior Health PlanAmerican Behavioral HealthBright HealthCareBlue Cross Blue ShieldCare Improvement PlanCare N CareCignaCompSychGHI - BMPGolden RuleGroup and Pension Administrator(GPA)HealthScopeHealthSmart (Network)HumanaMagellan Behavioral HealthMedicareMolina Texas HealthcareMulitiplan (Network)Mutual of Omaha Medicare Advantage PlanNew Era Life InsurancePHCS (Network)Scott & White Health PlanSilver Back TPATricare East RegionTricare For LifeTriwestTriwestUMRUnited HealthCareSecondary Insurance ID #Secondary Insurance Group #Appointment Reason*Select your Appointment ReasonAddictionAnxietyAttention-Deficit / Hyperactivity Disorder (ADHD)Autism Spectrum Disorder (ASD) (not testing)Bipolar / Mood DisordersDementiaDepressionEating DisordersMood DisordersObsessive-Compulsive-Disorder (OCD)Personality DisordersPhobiasPost-Traumatic-Stress-Disorder (PTSD)PsychosisPsychotic Disorders / SchizophreniaSchizophrenia & Schizoaffective DisordersSeasonal Affective DisorderSubstance Use DisorderTMSotherOther Reason*Appointment Reason Description*Appointment Preferred Date & TimeAppointment Preferred Date* Date Format: MM slash DD slash YYYY New PatientPatient's Last name* Last Name Date of Birth* Date Format: MM slash DD slash YYYY ageWe apologize for the inconvenience and we only see patients 16 years of age or older.*Do you have an open legal case or court case? Workers Compensation or Child Protective Services (CPS) Hearing?YesNowe apologize for the inconvenience, we do not specialize in these matters and we cannot make the appointment.Are you already ON any pain-control-medication (like hydrocodone, Percocet, Tylenol w/codeine, pain controlling patches, or any opioids)? Please be advised that we will NOT be able to prescribe any benzodiazepines(example Xanax, Klonopin, Valium, Ativan)due ti DEA regulations.Already On any pain-control-medication*YesNoPlease contact our Appointment Team at 817-488-8998 ext 2 to further assist youI acknowledge that urine sample* I Agree (Mandatory) I acknowledge that urine sample will be asked for a Urine Drug Screen, either at the office of Mid Cities Psychiatry or through an accredited laboratory within 48 hours of Mid Cities Psychiatry’s request. If the Urine Drug Screen is (1) positive for substances not prescribed or (2) negative for medications prescribed by a provider engaged in your care and treatment, Mid Cities Psychiatry has the right to decline any further prescriptions.I acknowledge that coming to appointment does not guarantee that control-medication* I Agree (Mandatory) I acknowledge that coming to appointment does not guarantee that control-medication will be prescribed. It’s up to the Provider’s discretion when they meet the patient.RCN (Rescheduling / Cancellation / No-Shows) Policy:* I agree (Mandatory) 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. RCN Fee Schedule; • All meds management 40 minutes appointment no-show fees would be $150.00 • All therapist's appointment no-show fees would be $150.00 • All 20 minutes appointment no-show fees would be $75.00 My Contact InformationPhone Number*Email* Address*Street AddressCity*State / Province / Region*Zip/Postal Code*My InsuranceInsuranceSelf-payPrimary InsurancePrimary Insurance*Select Primary InsuranceAetnaAllsaverAmbetter From Superior Health PlanAmerican Behavioral HealthBlue Cross Blue ShieldBright HealthCareCare Improvement PlanCare N CareCignaCompSychGHI - BMPGolden RuleGroup and Pension Administrator(GPA)HealthScopeHealthSmart (Network)HumanaMagellan Behavioral HealthMedicareMolina Texas HealthcareMulitiplan (Network)Mutual of Omaha Medicare Advantage PlanNew Era Life InsurancePHCS (Network)Scott & White Health PlanSilver Back TPATricare East RegionTricare For LifeTriwestTriwestUMRUnited HealthCareOther InsuranceOther Insurance*Primary Insurance ID #*Primary Insurance Group #Please upload your Insurance cardPlease provide the front image of your insurance card*Please Provide the back image of your insurance card*Please upload your Driver's LicensePlease provide the front image of your Driver's License*Please provide the back image of your Driver's License*Secondary Insurance--Select Optional--AetnaAllsaverAmbetter From Superior Health PlanAmerican Behavioral HealthBlue Cross Blue ShieldCare Improvement PlanCare N CareCignaCompSychGHI - BMPGolden RuleGroup and Pension Administrator(GPA)HealthScopeHealthSmart (Network)HumanaMagellan Behavioral HealthMedicareMolina Texas HealthcareMulitiplan (Network)Mutual of Omaha Medicare Advantage PlanNew Era Life InsurancePHCS (Network)Scott & White Health PlanSilver Back TPATricare East RegionTricare For LifeTriwestTriwestUMRUnited HealthCareSecondary Insurance ID #Secondary Insurance Group #Appointment ReasonAppointment Reason*Select Appointment ReasonAddictionAnxietyAttention-Deficit / Hyperactivity Disorder (ADHD)Autism Spectrum Disorder (ASD) (not testing)Bipolar / Mood DisordersDementiaDepressionEating DisordersMood DisordersObsessive-Compulsive-Disorder (OCD)Personality DisordersPhobiasPost-Traumatic-Stress-Disorder (PTSD)PsychosisPsychotic Disorders / SchizophreniaSchizophrenia & Schizoaffective DisordersSeasonal Affective DisorderSubstance Use DisorderTMSotherOther Reason*Appointment Reason Description*PHQ-9Please 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….Little interest or pleasure in doing things*Not At AllSeveral DaysMore Than Half of the DaysNearly Every DayFeeling down, depressed, or hopeless*Not At AllSeveral DaysMore Than Half of the DaysNearly Every DayTrouble falling or staying asleep, or sleeping too much*Not At AllSeveral DaysMore Than Half of the DaysNearly Every DayFeeling tired or having little energy*Not At AllSeveral DaysMore Than Half of the DaysNearly Every DayPoor appetite or overeating*Not At AllSeveral DaysMore Than Half of the DaysNearly Every DayFeeling bad about yourself — or that you are a failure or have let yourself or your family down*Not At AllSeveral DaysMore Than Half of the DaysNearly Every DayTrouble concentrating on things, such as reading the newspaper or watching television*Not At AllSeveral DaysMore Than Half of the DaysNearly Every DayMoving 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 AllSeveral DaysMore Than Half of the DaysNearly Every DayThoughts that you would be better off dead or of hurting yourself in some way*Not At AllSeveral DaysMore Than Half of the DaysNearly Every DayNot At AllSeveral DaysMore Than Half of the DaysNearly Every DayYour PHQ-9 Scale Total Score IsIf 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?*Not difficult at allSomewhat difficultVery difficultExtremely difficultDo you have a Psychologist?*YesNoIf yes, please enter the following:Name*City*State*Contact Information*Do you have a Psychotherapist?*YesNoIf yes, please enter the following:Name*City*State*Contact Infomation*Appointment Preferred Date & TimeAppointment Date & TimeSubject to your eligibility, our appointment will call you ASAP to schedule an appointment for you on the next available appointment slot.Appointment Preferred Date* Date Format: MM slash DD slash YYYY Appointment Preferred Time*8:00 AM - 12:00 PM1:00 PM - 3:40 PMN/AHow Did You Hear About Us*Select OptionReferred by a FriendReferred by our PatientReferred by a ProviderSocial Media (Twitter, Facebook, LinedIn)Search Engine (Google, Yahoo, etc.)Blog or PublicationCustomer TestimonialsName of the Provider* Δ This iframe contains the logic required to handle Ajax powered Gravity Forms.