# Make An Appointment! Please Choose Below New PatientExisting Patient Date Date Format: MM slash DD slash YYYY Patient's 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 you.I acknowledge that urine sample*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 Agree (Mandatory) I acknowledge that coming to appointment does not guarantee that control-medication* 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. I Agree (Mandatory) 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* Street Address*City*State / Province / Region*State* Select Your StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State 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*Accepted file types: jpg, png, pdf.Please Provide the back image of your insurance card*Accepted file types: jpg, png, pdf.Please upload your Driver's LicensePlease provide the front image of your Driver's License*Accepted file types: jpg, png, pdf.Please provide the back image of your Driver's License*Accepted file types: jpg, png, pdf.Secondary InsuranceSelect Secondary 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 HealthCareN/ASecondary Insurance ID #Secondary Insurance Group #How 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*Specialty*Phone Number*Fax Number*Reason for Visit*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 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 AllSeveral DaysMore Than Half of the DaysNearly Every Day2.) Feeling down, depressed, or hopeless*Not At AllSeveral DaysMore Than Half of the DaysNearly Every Day3.) Trouble falling or staying asleep, or sleeping too much*Not At AllSeveral DaysMore Than Half of the DaysNearly Every Day4.) Feeling tired or having little energy*Not At AllSeveral DaysMore Than Half of the DaysNearly Every Day5.) Poor appetite or overeating*Not At AllSeveral DaysMore Than Half of the DaysNearly Every Day6.) Feeling 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 Day7.) Trouble concentrating on things, such as reading the newspaper or watching television*Not At AllSeveral DaysMore Than Half of the DaysNearly Every Day8.) 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 AllSeveral DaysMore Than Half of the DaysNearly Every Day9.) Thoughts 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?*Select OptionNot difficult at allSomewhat difficultVery difficultExtremely difficultDo you have a Psychotherapist?*YesNoName*Email* Phone Number*Fax Number*City*State* Select Your StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Date of last visit* Date Format: MM slash DD slash YYYY Do you have a Psychologist?*YesNoName*Email* Phone Number*Fax Number*City*State* Select Your StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Date of last visit* Date Format: MM slash DD slash YYYY Section BreakMid 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 depressionWould you like to be contacted by a patient advocate to know more about TMS Therapy?*YesNoADHDPlease answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today’s appointment. Part A1.) How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?*NeverRarelySometimesOftenVery Often2.) How often do you have difficulty getting things in order when you have to do a task that requires organization?*NeverRarelySometimesOftenVery Often3.) How often do you have problems remembering appointments or obligations?*NeverRarelySometimesOftenVery Often4.) When you have a task that requires a lot of thought, how often do you avoid or delay getting started?*NeverRarelySometimesOftenVery Often5.) How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?*NeverRarelySometimesOftenVery Often6.) How often do you feel overly active and compelled to do things, like you were driven by a motor?*NeverRarelySometimesOftenVery Often Part B7.) How often do you make careless mistakes when you have to work on a boring or difficult project?*NeverRarelySometimesOftenVery Often8.) How often do you have difficulty keeping your attention when you are doing boring or repetitive work?*NeverRarelySometimesOftenVery Often9.) How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?*NeverRarelySometimesOftenVery Often10.) How often do you misplace or have difficulty finding things at home or at work?*NeverRarelySometimesOftenVery Often11.) How often are you distracted by activity or noise around you?*NeverRarelySometimesOftenVery Often12.) How often do you leave your seat in meetings or other situations in which you are expected to remain seated?*NeverRarelySometimesOftenVery Often13.) How often do you feel restless or fidgety?*NeverRarelySometimesOftenVery Often14.) How often do you have difficulty unwinding and relaxing when you have time to yourself?*NeverRarelySometimesOftenVery Often15.) How often do you find yourself talking too much when you are in social situations?*NeverRarelySometimesOftenVery Often16.) When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?*NeverRarelySometimesOftenVery Often17.) How often do you have difficulty waiting your turn in situations when turn-taking is required?*NeverRarelySometimesOftenVery Often18.) How often do you interrupt others when they are busy?*NeverRarelySometimesOftenVery OftenGeneralized 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 AllSeveral DaysMore Than Half of the DaysNearly Every Day2.) Not being able to stop or control worrying?*Not At AllSeveral DaysMore Than Half of the DaysNearly Every Day3.) Worrying too much about different things?*Not At AllSeveral DaysMore Than Half of the DaysNearly Every Day4.) Trouble relaxing?*Not At AllSeveral DaysMore Than Half of the DaysNearly Every Day5.) Being so restless that it is hard to sit still?*Not At AllSeveral DaysMore Than Half of the DaysNearly Every Day6.) Becoming easily annoyed or irritable?*Not At AllSeveral DaysMore Than Half of the DaysNearly Every Day7.) Feeling afraid as if something awful might happen?*Not At AllSeveral DaysMore Than Half of the DaysNearly Every DayIf you checked off any of the problems, Not difficult at all how difficult have these problems made it for you to do your work, Somewhat difficult take care of things at home, Very difficult or get along with other people?*Select OptionNot difficult at allSomewhat difficultVery difficultExtremely difficultYour GAD Scale Total Score IsAnxiety level based on score isAnxiety level based on score isAnxiety level based on score isAnxiety level based on score isDo You Drink Alcohol?*YesNoRapid Mood Screener (RMS)Are you among the millions of people who have depressive symptoms? Answer the following questionnaire about your medical history and provide it to your doctor or nurse to assist in an important conversation about your mood. Please select one response for each question. You can complete the RMS in less than 2 minutes.1.) Have there been at least 6 different periods of time (at least 2 weeks) when you felt deeply depressed?*YesNo2.) Did you have problems with depression before the age of 18?*YesNo3.) Have you ever had to stop or change your antidepressant because it made you highly irritable or hyper?*YesNo4.) Have you ever had a period of at least 1 week during which you were more talkative than normal with thoughts racing in your head?*YesNo5.) Have you ever had a period of at least 1 week during which you felt any of the following: unusually happy; unusually outgoing; or unusually energetic?*YesNo6.) Have you ever had a period of at least 1 week during which you needed much less sleep than usual?*YesNoQuality of Life Enjoyment and Satisfaction Questionnaire – Short Form (Q-LES-Q-SF)Taking everything into consideration, during the past week how satisfied have you been with your………1.) Physical health?*Very PoorPoorFairGoodVery Good2. Mood?*Very PoorPoorFairGoodVery Good3.) Work?*Very PoorPoorFairGoodVery Good4.) Household activities?*Very PoorPoorFairGoodVery Good5.) Social relationships?*Very PoorPoorFairGoodVery Good6.) Family relationships?*Very PoorPoorFairGoodVery Good7.) Leisure time activities?*Very PoorPoorFairGoodVery Good8.) Ability to function in daily life?*Very PoorPoorFairGoodVery Good9.) Sexual drive, interest and/or performance?*Very PoorPoorFairGoodVery GoodIn what aspect of your Sexual drive, interest and/or performance?*10.) Economic status?*Very PoorPoorFairGoodVery Good11.) Living/housing situation?*Very PoorPoorFairGoodVery GoodIn what aspect of your Living/housing situation?*12.) Ability to get around physically without feeling dizzy or unsteady or falling?*Very PoorPoorFairGoodVery GoodIn what aspect of your vision in terms of ability to get around physically without feeling dizzy or unsteady or falling?*13.) Your vision in terms of ability to do work or hobbies?*Very PoorPoorFairGoodVery GoodIn what aspect of your vision in terms of ability to do work or hobbies?*14.) Overall sense of well being?*Very PoorPoorFairGoodVery Good15.) Medication? (If not taking any, just leave item blank.)Very PoorPoorFairGoodVery Good16.) How would you rate your overall life satisfaction and contentment during the past week?*Very PoorPoorFairGoodVery GoodPIFPrevious Psychiatric DiagnosisDiagnosis*Year Diagnosed*Treating Provider*Do you have an Additional Previous Psychiatric Diagnosis?*YesNoSection BreakPPD-2Diagnosis*Year Diagnosed*Treating Provider*Do you have an Additional Previous Psychiatric Diagnosis?*YesNoSection BreakPPD-3Diagnosis*Year Diagnosed*Treating Provider*Do you have an Additional Previous Psychiatric Diagnosis?*YesNoSection BreakPPD-4Diagnosis*Year Diagnosed*Treating Provider*Do you have an Additional Previous Psychiatric Diagnosis?*YesNoSection BreakPPD-5Diagnosis*Year Diagnosed*Treating Provider*Previous Psychiatric Hospitalizations/RehabName*Year*Do you have an Additional Previous Psychiatric Hospitalizations/Rehab?YesNoSection BreakPPHR-1Name*Year*Do you have an Additional Previous Psychiatric Hospitalizations/Rehab?YesNoSection BreakPPHR-2Name*Year*Do you have an Additional Previous Psychiatric Hospitalizations/Rehab?YesNoSection BreakPPHR-3Name*Year*Do you have an Additional Previous Psychiatric Hospitalizations/Rehab?YesNoSection BreakPPHR-4Name*Year*Previous Psychiatric/Sleep MedicationsMedications Name*Dose*Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Side Effects*Do you have an Additional Medication?*YesNoSection BreakPPSMM-2Medications Name*Dose*Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Side Effects*Do you have an Additional Medication?*YesNoSection BreakPPSMM-3Medications Name*Dose*Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Side Effects*Do you have an Additional Medication?*YesNoSection BreakPPSMM-4Medications Name*Dose*Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Side Effects*Do you have an Additional Medication?*YesNoSection BreakPPSMM-5Medications Name*Dose*Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Side Effects*Do you have an Additional Medication?*YesNoSection BreakPPSMM-6Medications Name*Dose*Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Side Effects*Do you have an Additional Medication?*YesNoSection BreakPPSMM-7Medications Name*Dose*Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Side Effects*Medication AllergiesDo you have any Medication Allergies?*YesNoSection BreakName*Reaction*Do you have an Additional Medication Allergies?*YesNoSection BreakMA-2Name*Reaction*PharmacyName*City*State* Select Your StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Phone #*Do you have an Additional Pharmacy?*YesNoSection BreakPharmacy-2Name*City*State* Select Your StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Phone #*Medical History - (seizures disorders, diabetes, heart problems etc.)Diagnosis*Year Diagnosed*Treating Provider*Do you have an Additional Medical History?*YesNoSection BreakMH-2Diagnosis*Year Diagnosed*Treating Provider*Do you have an Additional Medical History?*YesNoSection BreakMH-3Diagnosis*Year Diagnosed*Treating Provider*Do you have an Additional Medical History?*YesNoSection BreakMH-4Diagnosis*Year Diagnosed*Treating Provider*Do you have an Additional Medical History?*YesNoSection BreakMH-5Diagnosis*Year Diagnosed*Treating Provider*Do you have an Additional Medical History?*YesNoSection BreakMH-6Diagnosis*Year Diagnosed*Treating Provider*Past Surgical HistoryProcedure*Date Of Procedure* Date Format: MM slash DD slash YYYY Provider Name*Do you have an Additional Past Surgical History?*YesNoSection BreakPSH-2Procedure*Date Of Procedure* Date Format: MM slash DD slash YYYY Provider Name*Do you have an Additional Past Surgical History?*YesNoSection BreakPSH-3Procedure*Date Of Procedure* Date Format: MM slash DD slash YYYY Provider Name*Do you have an Additional Past Surgical History?*YesNoSection BreakPSH-4Procedure*Date Of Procedure* Date Format: MM slash DD slash YYYY Provider Name*Family Psychiatric HistoryRelationship*Choose your relationshipMotherFatherBrotherSisterSonDaughterLiving/Age passed*Age*Psychiatric History*Relationship*Choose your relationshipMotherFatherBrotherSisterSonDaughterLiving/Age passed*Age*Psychiatric History*Relationship*Choose your relationshipMotherFatherBrotherSisterSonDaughterLiving/Age passed*Age*Psychiatric History*Relationship*Choose your relationshipMotherFatherBrotherSisterSonDaughterLiving/Age passed*Age*Psychiatric History*Do you have an Additional Family to add?*YesNoSection BreakRelationship*Choose your relationshipMotherFatherBrotherSisterSonDaughterLiving/Age passed*Age*Psychiatric History*Legal HistoryDo you have a Current or Previous Conviction?*YesNoSection BreakArrest Date* Date Format: MM slash DD slash YYYY Charge*Convicted*Sentence*Do you have an Additional Legal History?*YesNoSection BreakLH-2Arrest Date* Date Format: MM slash DD slash YYYY Charge*Convicted*Sentence*Do you have an Additional Legal History?*YesNoSection BreakLH-3Arrest Date* Date Format: MM slash DD slash YYYY Charge*Convicted*Sentence*ProbationAre you currently on Probation?*YesNoSection BreakParole?*Ending Date?* Date Format: MM slash DD slash YYYY LawsuitsAre you involved in any lawsuits?*YesNoCourt DatesDo you have any upcoming Court Dates?*YesNoSection BreakReasonMilitary ServiceDo you have a Military Service?*YesNoSection BreakType*When* Date Format: MM slash DD slash YYYY Was your Discharge Honorable or Dishonorable?*HonorableDishonorablePlease explain*Were you involved in a any combat?*YesNoPlease describe Combat experience*Are you troubled now by your military experience?*YesNoPlease describe your trouble by military experience*Previous Substance AbuseWere you involved Substance Abuse?*YesNoSection BreakName of Substance*What age started using*What age stopped using*Do you have an Additional Substance Abuse?*YesNoSection BreakPSA-2Name of Substance*What age started using*What age stopped using*Do you have an Additional Substance Abuse?*YesNoSection BreakPSA-3Name of Substance*What age started using*What age stopped using*Current Substance AbuseAre you currently involved in Substance Abuse?*YesNoSection BreakName of Substance*What age started using*How much do you use*Do you have an Additional Substance Abuse?*YesNoSection BreakCSA-2Name of Substance*What age started using*How much do you use*Do you have an Additional Substance Abuse?*YesNoSection BreakCSA-3Name of Substance*What age started using*How much do you use*SmokeDo you smoke?*YesNoVapeDo you Vape?*YesNoDrinkDo you Drink?*YesNoAlcohol Screening Questionnaire ( AUDIT )Our clinic asks all patients about alcohol use at least once a year. Drinking alcohol can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below.1.) How often do you have a drink containing alcohol?*NeverMonthly or Less2-4 Times a Month2-3 Times a Week4 or more Times a Week2.) How many drinks containing alcohol do you have on a typical day when you are drinking?*0-23 or 45 or 67 - 910 or more3.) How often do you have four or more drinks on one occasion*NeverLess than monthlyMonthlyWeeklyDaily or almost daily4.) How often during the last year have you found that you were not able to stop drinking once you had started?*NeverLess than monthlyMonthlyWeeklyDaily or almost daily5.) How often during the last year have you failed to do what was normally expected of you because of drinking?*NeverLess than monthlyMonthlyWeeklyDaily or almost daily6.) How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?*NeverLess than monthlyMonthlyWeeklyDaily or almost daily7.) How often during the last year have you had a feeling of guilt or remorse after drinking?*NeverLess than monthlyMonthlyWeeklyDaily or almost daily8.) How often during the last year have you been unable to remember what happened the night before because of your drinking?*NeverLess than monthlyMonthlyWeeklyDaily or almost daily9.) Have you or someone else been injured because of your drinking?*NoYes, but not in the last yearYes, in the last year10.) Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?*NoYes, but not in the last yearYes, in the last yearHave you ever been in treatment for an alcohol problem?*Select OptionNeverCurrentlyIn The PastSocial History/Marital StatusMarital Status*Please choose your marital statusSingleMarriedDivorcedSeperatedWidowedSocial History/Sexual OrientationSexual Orientation*Please choose your sexual orientationAsexualBisexualGayHeterosexualLesbianPansexualEmployment/EducationAre you Employed?*YesNoSection BreakEmployed*Choose your employment statusFull TimePart TimeHighest Schooling*Choose your highest schoolingHight SchoolBachelorsMastersPhDMD/DOCompany Name*Occupation*Section BreakNot-Employed*Choose your highest schoolingDisabledRetiredUnemployedPhysical ExamPlease rate your Thought Process*Choose your thought processGoodFairPoorPlease rate your Long Term Memory*Choose your long term memoryGoodFairPoorPlease rate your Short Term Memory*Choose your short term memoryGoodFairPoorPlease rate your Concentration*Choose your concentrationGoodFairPoorSuicidal IdeationsAre you having Suicidal Ideations?*YesNoDo You Have a Plan?*YesNoWhat is your plan?*Homicidal IdeationsAre you having Homicidal Ideations?*YesNoDo You Have a Plan?*YesNoWhat is your plan?*HallucinationsDo you Hallucinations?*YesNoDelusionsAre you Delusional?*YesNoPossession of GunDo you have a gun?*YesNoAppointment Date & TimeSubject to your eligibility, our appointment will call you ASAP to schedule an appointment for you on the next available appointment slot. CAPTCHA Δ 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