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Date
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Date
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Date Submitted
Are You An Existing Patient?* This field is hidden when viewing the form
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What is your MRN?
Patient's Last Name*
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Date of Birth*
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Date of Birth* This field is hidden when viewing the form
Age*
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Date
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Date of Birth copy
We apologize for the inconvenience, we only see patients 16 years of age or older. This field is hidden when viewing the form
Do you have a new phone #?* This field is hidden when viewing the form
New Phone #*
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Same Phone #*
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What is your email address?*
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Do you have a new email?* This field is hidden when viewing the form
Have you moved?* Street Address*
City*
State* Zip/Postal Code*
Upload front image of your Driver's License.* Upload back image of your Driver's License.*
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. This field is hidden when viewing the form
Do you have any changes in Medication?* This field is hidden when viewing the form
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?* This field is hidden when viewing the form
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?* This field is hidden when viewing the form
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 Primary Care Physician?* Who is your Primary Care Provider?*
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When was your last visit to 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
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Copy Date Health & Physical?
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Do you have a New Insurance?* Upload front image of your Insurance Card* Upload back image of your Insurance Card*
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Do you have a New Secondary Insurance?* This field is hidden when viewing the form
Secondary Insurance* Select Optional Aetna Allsaver 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
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Secondary Insurance ID #
Secondary Insurance Group #
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Appointment Reason* Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Esketamine (Sparavto) Ketamine Mood Disorders Obsessive-Compulsive-Disorder (OCD) Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS Other
Other Reason
Appointment Reason Description*
Please share your treatment Goals ?
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What is your long term treatment goal?
Suicidal Ideations (CCSR) In the past month have you wished you were dead or wished you could go to sleep and not wake up?* In the past month have you actually had any thoughts of killing yourself?* In the past month have you ever done anything, started to do anything, or prepared to do anything to end your life?*
Immediate Steps for Your Safety Based on the outcomes of your recent safety assessment at Mid Cities Psychiatry,
we urge you to take the following immediate steps:
If you need immediate help, please call 911.
For more information, visit our Patient Resources webpage.
In the past month have you had these thoughts and had some intention of acting on them?* In the past month have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?* This field is hidden when viewing the form
Have you ever done anything, started to do anything, or prepared to do anything to end your life? This field is hidden when viewing the form
Was this within the past three months? This field is hidden when viewing the form
Patients categorized as
Homicidal Ideations Are you having Homicidal Ideations?*
PLEASE Go To Your Nearest Emergency Room or Call 911.
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Do You Have a Plan?* What is your plan?*
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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 attach it here 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 Question 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
Consent* I Agree (Mandatory) 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.*
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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.* This field is hidden when viewing the form
RCN 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
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.* This field is hidden when viewing the form
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Do you have a Psychotherapist?* 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* This field is hidden when viewing the form
Date of last visit*
MM slash DD slash YYYY
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Do you have a Psychologist?* 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* This field is hidden when viewing the form
Date of last visit*
MM slash DD slash YYYY
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TMS Mid Cities Psychiatry provides Transcranial Magnetic Stimulation aka TMS Therapy.TMS Therapy is an alternative treatment for patients suffering from depression for whom medication has proven ineffective. and provides new hope for people who want to reduce or possibly eliminate the use of prescription medications to treat their depression. This field is hidden when viewing the form
Would you like to be contacted by a patient advocate to know more about TMS Therapy?* This field is hidden when viewing the form
Please specify your preferred future appointment date? This field is hidden when viewing the form
Providers * 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 "Kaye" Chiu, MPAS, PA-C
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Appointment Date *
MM slash DD slash YYYY
Subject to your insurance eligibility (if you have insurance), our appointment team Please note that we cannot guarantee the requested appointment date. Our dedicated Appointment Team Please Note, processing your form may take 1-2 minutes.
only once and wait for the thank you message. 
