Make An Appointment! 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 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 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 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 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* 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 the full $75 cancellation/no show fee (so to avoid our billing company billing you $75, please call in more than 24 business hours).. 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.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 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 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*Appointment Preferred Date & TimeAppointment Preferred Date* Date Format: MM slash DD slash YYYY Appointment Preferred Time*8:00 AM - 12:00 PM1:00 PM - 3:40 PMHow Did You Hear About Us*Referred 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*CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.