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Date

Email Address*

Last Name*

Gender*

Date of Birth*

We apologize for the inconvenience, 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?

Yes

Are you already ON any pain-control medication such as Hydrocodone, Percocet, Tylenol w/ Codeine, Pain-controlling patches, Opioids, etc.? Please be advised that we will NOT be able to prescribe any Benzodiazepines such as Xanax, Klonopin, Valium, or Ativan due to DEA regulations.*

Yes

RCN (Rescheduling / Cancellation / No-Shows) Policy:
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.

We apologize for the inconvenience, we do not specialize in these matters and we cannot make the appointment.

Please contact our Appointment Team at (817)-369-9490 ext 2 to further assist you.

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Section Address

Address

City

State

ZIP Code

Cell #*

Work #

Race

Payment Type

Payment Type*

Primary Insurance

Self Pay

Primary Insurance*

Other Insurance*

Primary Insurance ID

Primary Insurance Group #

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Secondary Insurance*

Secondary Insurance ID

Secondary Insurance Group #

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So we can support you as quickly as possible, please tell us what you’re reaching out to us:*

Mental health concerns (depression, anxiety, thoughts of self-harm)

Substance use concerns (alcohol, opioids, stimulants, etc.)

Both mental health and substance use

Other / not sure yet

When is the best time to contact you?*

Call me as soon as possible

Morning (9:00 AM – 12:00 PM)

Afternoon (1:00 PM – 5:00 PM)

Evening (after 5:00 PM)

Eligibility Form

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