FMG Integrative Health Consultants

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Are you currently located in and reside in Texas?

FMG provides care for Texas residents only. This is a legal requirement, not a preference

Yes-I am currently located and reside in Texas No-I am located outside of Texas

Reason for care

What is the reason for seeking care?

This helps Dr. Mo have some baseline understanding of what your concerns are.

Anxiety, worry, or chronic stress Depression, low mood, or persistent sadness Burnout either professionally, personally or both Perimenopause-related mood, anxiety, sleep or cognitive changes Difficulty focusing, concentrating, or managing executive function Irritability, mood shifts or emotional dysregulation Grief, loss or a major life transition A sense of functioning on the outside while struggling on the inside Substance use(alcohol, nicotine, and/or illicit substances) Something else( will discuss more with Dr. Mo)

What kind of care is being sought?

FMG Integrative Health is a discreet, high touch private pay practice; physician-led by board certified psychiatrist, Dr. Mo who provides medication management, psychotherapy and an integrative approach to treatment.

Psychotherapy Medication, if recommended Integrative and/or holistic approach to my wellbeing Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Are you currently having thoughts to harm yourself or others(suicidal thoughts or homicidal thoughts, plan or intent)?

If you selected "Yes-I am in crisis and need immediate support" please call or text 988(Suicide & Crisis Lifeline), call 911, or go to your nearest emergency room immediately. FMG is an outpatient telehealth and clinic-based practice and is not a crisis service. The FMG team will follow-up with you, but crisis support requires immediate intervention that FMG cannot provide.

No thoughts of self-harm No thoughts to harm others Yes-I have had thoughts of self-harm but do not intend to act on them Yes-I have had thoughts to harm others but do not intend to act on them Yes-I am in crisis, I am having thoughts and intent to harm myself and/or others and I need immediate support

Administrative

Inquiry reason

Let us know what we can help you with!

How did you hear about FMG Integrative Health and/or Dr. Felecia Garner(Dr. Mo)

Enter how you were referred to our services

Google or online search Therapist directory SimplePractice directory Referred by therapist, physician or other healthcare provider Referred by a friend, family member or colleague A professional or community organization LinkedIn, Instagram or other social media platform Other

Are you 17 years of age or older?

FMG works with adults and young adults ages 17 years and older

Yes-I am 17 or older No-I am under 17 No-my child is under 17 but I was referred to FMG and need to discuss with Dr. Garner(Dr. Mo).

Client Preferences

Preferred appointment times

Morning Afternoon Evening

Is there anything that you believe is important and you would like Dr. Mo to know?

For example: who specifically referred you, what you'd like to focus on or anything else that is important to you.

Limited to 600 characters

Billing & Payment

FMG is a private-pay practice. We do not bill insurance directly. Are you open to this model?

We can provide a superbill for potential out-of-network reimbursement upon request. Many clients find that private-pay removes the limitations that insurance may place on their care.

Yes-I am comfortable with private pay Yes-I am comfortable with private pay and plan to seek out-of-network reimbursement from my insurer No-I need an insurance-based practice

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.