Scheduled Appointment Form

To ensure the best possible service, please complete the form in its entirety and click submit at the end to help us understand your needs and provide you with holistic care.
The form takes 5-10 minutes to complete. If you can’t complete it electronically, please call us 817-488-8998 ext 2 or e-mail us at info@MidCitiesPsychiatry.com to assist you.

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Date
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Date Submitted
What is your MRN?*
Patient's Last Name*
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Date of Birth*
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Date of Birth*
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Age*
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Copy Age*
We apologize for the inconvenience, we only see patients 16 years of age or older.
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Choose Your Provider*
- Ashley Ibbotson, PhD
- Bailey Hofer, MSC, PA-C
- Brenda Broadnax, MS, LPC
- Debora Simpson, MA, LPC
- Haylee Hughes, MPAS, PA-C
- Heather Spengler, MSC.PMHNP-BC
- Jackquelyn D. Williams, DNP, APRN, FNP-C, PMHNP-BC
- Jasmine Webbs, MSW, LCSW
- 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
- Triet M. La, DO, MS
- Wing Kei Chiu, MPAS, PA-C
Appointment Date*
MM slash DD slash YYYY
Time

Hours :

Minutes

AM/PM
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Copy Appointment Date
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Do you have a new phone #?*
- Yes
- No
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New Phone #*
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Do you have a new email?*
- Yes
- No
What is your email address?*
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Have you moved?*
- Yes
- No
New Address
Street Address*
City*
State*
State
Zip/Postal Code*
Please upload if you have a new Driver's License
Please provide the front image of your Driver's License in JPG or PDF format.
Accepted file types: pdf, jpg, Max. file size: 120 MB.
Please provide the back image of your Driver's License in JPG or PDF format.
Accepted file types: pdf, jpg, Max. file size: 120 MB.
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.
Your understanding is greatly appreciated.
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Do you have any changes in Medication?*
- Yes
- No
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Do you have any changes in Medication? (YES)
Medications Name*
Dose*
Start Date*
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End Date*
MM slash DD slash YYYY
Side Effects*
Do you have an additional Medication Changes?*
- Yes
- No
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MDC-2
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?*
- Yes
- No
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MDC-3
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 Insurance?*
- Yes
- No
Please upload if you have a new Insurance card
Please provide the front image of your Insurance Card in JPG or PDF format.
Accepted file types: pdf, jpg, Max. file size: 120 MB.
Please provide the back image of your Insurance Card in JPG or PDF format.
Accepted file types: pdf, jpg, Max. file size: 120 MB.
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.
Your understanding is greatly appreciated.
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Do you have a New Secondary Insurance?*
- Yes
- No
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Secondary Insurance*
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Secondary Insurance ID #
Secondary Insurance Group #
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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.*
- I Agree (Mandatory)
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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
    • Psychologists' appointment no-show fees would be $150.00 per hour
    • Therapist's appointment no-show fees would be $150.00
    • 20 minutes meds management appointment no-show fees would be $75.00
To avoid these charges, please reschedule or cancel in more than 24 business hours in advance, considering our office closure on weekends and holidays.
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.*
- I Agree (Mandatory)
Psychiatric Health - Your Current State
How have you felt since your previous visit?*
How do you feel since you began this treatment?*
Physical Health - Your Current State
Height (feet/inches)
Weight (pounds)*
Blood Pressure*
Pulse Rate (BPM)*
Temperature (Fahrenheit)
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Dependent Care Resources
Dependent Care Resources
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Do you need resources for the care of your dependents?*
- Yes
- No
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Psychiatric Advance Directive Question:
Psychiatric Advance Directive
Do you have a Psychiatric Advance Directive?*
- Yes
- No
Please provide your Psychiatric Advanced Directive in PDF format.
Accepted file types: pdf, Max. file size: 120 MB.
Would you like to create one?*
- Yes
- No
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Legal Need Resources
Legal Need Resources
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Are you in need of legal assistance or support?*
- Yes
- No
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Vocational Need Resources Question
Vocational Need Resources
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Do you need vocational assistance or support?*
- Yes
- No
Current Mental Health Care Providers
Do you have a Psychotherapist?*
- Yes
- No
Since your last visit, is your current Psychotherapist the same or a new one?*
- Same
- New
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Name*
Email*
Phone Number*
Fax Number*
City*
State*
State
Date of last visit*
MM slash DD slash YYYY
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Date of last visit*
MM slash DD slash YYYY
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Do you have a Psychologist?*
- Yes
- No
Do you have a Psychologist?*
- Yes
- No
Since your last visit, your current Psychologist same or a new one?*
- Same
- New
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Name*
Email*
Phone Number*
Fax Number*
City*
State*
State
Date of last visit*
MM slash DD slash YYYY
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Date of last visit*
MM slash DD slash YYYY
Current Stressors
Current Stressors
- Conflict with Children
- Conflict with Family
- Conflict with Siblings
- Emotional
- Financial Problems
- Health Problems
- Housing Problems
- Job Loss or Change
- Legal Problems
- Physical
- Poor Peer Relations
- Problems at Work
- Recent Death
- Recent Move
- Separation/Divorce
- Sexual
- Victim of Abuse
- Other
Other
Select the symptoms you are experiencing
- Aggression/Anger Outburst
- Anxiety
- Alcohol/Drug Abuse
- Avoidance of People
- Chest Pains
- Computer Addiction
- Depression
- Difficulty Thinking
- Difficulty Concentrating
- Dizziness
- Distractibility
- Eating Disorder
- Elevated Mood
- Excessive Crying
- Excessive Laughing
- Hallucinations
- Helplessness
- Impulsivity
- Irritability
- Memory Problems
- Muscle Tension
- Racing Thoughts
- Sexual Addiction
- Sleeping Problems
- Stressed Out
- Suicidal Thoughts
- Weight Gain/Loss
- Worrying
- Fatigue
- Gambling
- Headaches
- Hopelessness
- Indecisiveness
- Loneliness
- Mood Swings
- Panic Attacks
- Restless/On Edge
- Sexual Difficulties
- Snoring
- Stop Breathing
- Trembling
- Withdrawn
- Worthlessness
- Other
Other
Patient Health Questionnaire ( PHQ-9 )
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
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Not At All
Several Days
More Than Half of the Days
Nearly Every Day
Your PHQ-9 Scale Total Score Is
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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?*
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Based on your responses, Mid Cities Psychiatry provides various treatment alternatives. These include:
    • TMS (Transcranial Magnetic Stimulation) is a non-invasive therapy alternative for treatment-resistant depression.
    • SPRAVATO™ (Esketamine) Nasal Spray used in conjunction with oral antidepressants for treatment-resistant depression.
    • Ketamine is an innovative approach showing promising results quickly alleviating symptoms of depression and anxiety.
Would you like our patient advocate to contact you to assist you in the treatment option? Please indicate your preference:*
- TMS Therapy
- SPRAVATO™
- Ketamine
- Would Like To Know Best Treatment Option
- None
Suicidal Ideations
In the past month
Have you wished you were dead or wished you could go to sleep and not wake up?*
- Yes
- No
Suicidal Ideations
In the past month
Have you wished you were dead or wished you could go to sleep and not wake up?*
- Yes
- No
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Have you actually had any thoughts of killing yourself?*
- Yes
- No
Have you been thinking about how you might do this?*
- Yes
- No
Have you had these thoughts and had some intention of acting on them?*
- Yes
- No
Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?*
- Yes
- No
Have you ever done anything, started to do anything, or prepared to do anything to end your life?*
- Yes
- No
Was this within the past three months?*
- Yes
- No
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Patients categorized as
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Provider
Homicidal Ideations
Are you having thoughts of harming other people?*
- Yes
- Yes and I am afraid I may act on them
- No
Do You Have a Plan?*
- Yes
- No
What is your plan?*
Generalized Anxiety Disorder Questionnaire ( GAD-7 )
How often have you been bothered by the following problems? As you answer each question, select the radio button that best describes how you have felt and conducted yourself over the past 2 weeks.
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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Generalized Anxiety Disorder Questionnaire ( GAD-7 )
How often have you been bothered by the following problems? As you answer each question, select the radio button that best describes how you have felt and conducted yourself over the past 2 weeks.
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1. Feeling nervous, anxious or on edge?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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2. Not being able to stop or control worrying?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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3. Worrying too much about different things?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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4. Trouble relaxing?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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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
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6. Becoming easily annoyed or irritable?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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7. Feeling afraid as if something awful might happen?*
- Not At All
- Several Days
- More Than Half of the Days
- Nearly Every Day
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Your GAD Scale Total Score Is*
Physical Pain
Have you had physical pain in the last week?*
- Yes
- No
On this scale how bad was your pain?
Do you currenty have physical pain now?*
- Yes
- No
On this scale how bad was your pain?
Nutritional Status
Do you have food allergies?*
- Yes
- No
Have you had weight loss or gain of 10 pounds or more in the last 3 months?*
- Yes
- No
Have you had a decrease in food intake and/or appetite?*
- Yes
- No
Do you have dental problems?*
- Yes
- No
Do you have eating habits or behaviors that may be indicators of an eating disorder, such as binging or inducing vomiting?*
- Yes
- No
What are they?
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Nutritional Status Score Is (hidden)
You are identified as
You are identified as
You are identified as
You are identified as
You are identified as
You are identified as
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Abuse, Neglect, Trauma, Exploitation
Have you recently experienced any new trauma, abuse, neglect, or exploitation?*
- Yes
- No
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Please Explain:
Please Explain:*
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What trauma have you experienced?*
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Have you ever experienced trauma?*
- Yes
- No
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What trauma have you experienced?*
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Have you ever experienced abuse?*
- Yes
- No
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What abuse have you experienced?*
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Have you ever experienced neglect?*
- Yes
- No
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What neglect have you experienced?*
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Have you ever been exploited?*
- Yes
- No
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How have you been exploited?*
Please Note; processing your form may take 1-2 minutes. To avoid delays, kindly press the submit button only once and wait for the thank you message.
We appreciate your patience.

PLEASE Go To Your Nearest Emergency Room or Call 911.

Mid Cities Psychiatry is dedicated to your health and well-being.
We strongly encourage you to prioritize your health by scheduling an annual
physical examination with your primary care physician or a pain management
specialist. Contact your insurance provider, they can direct you to network
professionals. For out-of-pocket expenses, consider contacting
Dr. Rehan Khan, MD.

For more information, visit our Patient Resources webpage.

Mid Cities Psychiatry is dedicated to your health and well-being. Ensure you
schedule your annual check-up with your primary care physician or a nutritionist to
effectively manage your health. Contact your insurance provider, they can direct
you to network professionals. For out-of-pocket expenses, consider contacting
Dr. Saba Shabnam, MD
or
Dr. Mohammad Uddin
for personalized care.

For more information, visit our Patient Resources webpage.

At Mid Cities Psychiatry, we are dedicated to providing comprehensive support for
you throughout the treatment process. For psychiatric patients dealing with trauma,
abuse, neglect, or exploitation in the DFW area, we recommend reaching out to the
following resources:

Trauma Support Services of North Texas (TSSNT) at (972) 709-4904.

CK Family Services at (817) 516-9100.

Dallas Police Department's Victim Services at (214) 670-8675.

For more information, visit our Patient Resources webpage.

At Mid Cities Psychiatry, we're focused on ensuring comprehensive support for you
and your family throughout the treatment process. We recommend reaching out to
My Health My Resources (MHMR) of Tarrant County at 817-335-3022
or
JPS Health Network at 817-702-3100
for additional support in caring for your dependents.

For more information, visit our Patient Resources webpage.

Mid Cities Psychiatry recommends T. Daniel Hollaway for patients seeking to
create a Psychiatric Advance Directive at (713) 942-7900.

For more information, visit our Patient Resources webpage.

At Mid Cities Psychiatry, we are dedicated to providing comprehensive support for
you throughout the treatment process. For legal assistance, feel free to contact:
Legal Aid of NorthWest Texas at 800-955-3959.
Texas Advocacy Project at 800-374-HOPE.
SafeHaven of Tarrant County at 877-701-7233.

For more information, visit our Patient Resources webpage.

At Mid Cities Psychiatry, we are dedicated to providing comprehensive support for
you throughout the treatment process. For vocational assistance, feel free reaching
out to:
Texas Workforce Commission's Vocational Rehabilitation Program at
(512) 936-6400
Workforce Solutions for North Central Texas at (817) 413-4000
Total Transition Services (TTS) at (817) 617-2193

For more information, visit our Patient Resources webpage.

Scheduled Appointment Form

New Address

Please upload if you have a new Driver's License

Do you have any changes in Medication? (YES)

Please upload if you have a new Insurance card

RCN

Psychiatric Health - Your Current State

Physical Health - Your Current State

Dependent Care Resources

Dependent Care Resources

Psychiatric Advance Directive Question:

Psychiatric Advance Directive

Legal Need Resources

Legal Need Resources

Vocational Need Resources Question

Vocational Need Resources

Current Mental Health Care Providers

Current Stressors

Patient Health Questionnaire ( PHQ-9 )

Suicidal Ideations

Suicidal Ideations

Homicidal Ideations

Generalized Anxiety Disorder Questionnaire ( GAD-7 )

Generalized Anxiety Disorder Questionnaire ( GAD-7 )

Physical Pain

Nutritional Status

Abuse, Neglect, Trauma, Exploitation

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