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 Intake Forms

Once intake is completed you will be notified if we can continue with follow up care or to find a different provider if we don't have all the resources to better address your needs. So if you already have a psychiatrist now, don't cancel your appointment with them until you are accepted in our clinic. 

At Mid-Florida Psychiatry Center, a TelePsychiatry virtual clinic, Dr Vangala has Physician Associates and Psychiatric Nurse Practitioners (AHP’s)who work along with Dr Vangala in seeing patients for medication management, either during initial visit or follow up visits. If an AHP has done assessment and unable to review  with MD or the team are unable to come to conclusion of diagnosis and treatment plan, you may asked to schedule a follow up appointment prior to prescribing medication. We do not provide any emergency tele psych visits. Please visit your nearest emergency room or call 911 or 988 in case of emergency. 


Also, Dr Vangala is teaching Medical students, PA students and Nurse practitioner students in this clinic. You may come across these students, who are just gathering the information and learning from either Dr Vangala or his AHPs. Please notify the staff if any specific requests-like no Students.

Our providers are ONLY licensed in FL, hence patient need to be in Fl at the time of appointment, and meds will be sent to pharmacies in FL only. 

At the end of current DEA deadline (Dec 31, 2024), controlled medication such as Xanax, Ativan, Klonopin, Temazepam, Ambien, Lunesta etc., can only be prescribed via tele visits, if the patient meets certain criteria. These criteria are in the process of being finalized by DEA. 


By completing this paperwork, it’s implied that you are aware of the clinic setting/policy and are agreeing to be treated in this clinic.

Health History, Consent to Treatment and Other

Please fill out your contact information, insurance information, and health information to facilitate treatment, agreeing with clinics policies and procedures and agreeing to pay for services if your insurances declines or you have not met the deductibles, missed appointments, agreeing to consent for tele psychiatry visits and agreeing and consenting to treatment with medication as appropriate. 

Upload A Photo of Patient
Have Insurance?-Upload the Insurance cards
Upload Govt Issued ID (Front)
Ins Card Front
Ins Card Back
CURRENTLY taking Psychiatric medication?
CURRENTLY Seeing a Psychiatrist?
Any PAST Psychiatric Admissions to Hospitals?
Any PAST Counseling/ Treatment-OUT Patient
Any PAST Psychiatric medication?
Any PAST Suicide Attempts?
Do You Smoke?
Do You Drink Alcohol?
Do You use any Drugs
Are you ALLERGIC to any medication?
Anyone in the Family has/had Psychiatric Problems
Additional Documents
Additional Documents
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