Request an Appointment

Please fill out the form below to request an appointment

Please text us at (281) 500-8416 or email us at info@cipclinic.com for any questions

Note: Your privacy is very important to us. While we use a HIPAA compliant, secure version of Google Workspace, please take extra caution and do not share any personal health information (PHI) or medical details on this form. This form is only for general information and scheduling purposes. You will have a secure and confidential opportunity once your account is set up in our medical record system to share details about your care and what is bringing you in to our clinic.

You may view our Privacy Practices here.

What to expect next upon filling out our contact form:

  1. Insurance Verification: We will verify your insurance and notify you of any applicable copay, coinsurance, or deductible.

  2. We'll reach out to you with your expected responsibility based on your insurance plan. 

  3. Patient Account Setup: Once we confirm your patient responsibility with you, we will set up a patient account for you in our system called Tebra. This is our secure medical record system where you can complete intake/consent forms and sign necessary agreements.

  4. Once these steps are completed, we will assist you in scheduling your first appointment with our clinic. 

We look forward to supporting you on your journey to mental wellness!

Please keep in mind that the CIP Psychiatry is not a crisis clinic and does not have the resources to respond to a crisis or emergency situation. If you or someone you know is experiencing a mental health crisis, suicidal ideation, or homicidal ideation, please call 911 or go to your nearest emergency room.
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Please acknowledge that you have read and agree to our Privacy Practices. *
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Full Name *
Date of Birth *
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Email Address *
Phone Number *
Preferred Method of Contact *
Street Address *
Street Address 2
City *
State *
Zip Code *
By entering my mobile number above and selecting yes in the menu below, I agree to receive messages from CIP Psychiatry.
By entering my mobile number above and selecting yes in the menu below, I agree to receive messages from CIP Psychiatry. 

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Do you provide consent to receive SMS messages from CIP Psychiatry to the phone number provided above? *
Do you plan on using insurance or paying cash?
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Please enter your gender as listed on ID/insurance *
Please enter your insurance provider name. 
Note: This should be the name of your insurance company, not your personal name.

Please write "N/A" if not using insurance
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What is your Insurance Subscriber ID?

Please write "N/A" if not using insurance
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What is your Insurance Group Number?

Please write "N/A" if not using insurance
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Physical Location Requirement for Virtual Visits
Please note: Due to regulatory and legal requirements, for telehealth visits, you must be physically located in one of our providers’ licensed states at the time of your session. 

Dr. Shehram Majid is licensed in Washington, D.C. and Texas.

Latosha Jackson PMHNP-BC, DNP is licensed in Texas only 

Adesola Bakinson PMHNP-BC is licensed in Texas only 

Please acknowledge that you understand this requirement, which ensures our clinic remains in compliance with state laws.
Do you acknowledge that you understand the above requirement, which ensures our clinic remains in compliance with state laws? *
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Our clinic typically offers 1 hour long intake appointments to allow enough time to understand your concerns, gather important clinical history, and build a strong therapeutic alliance. 

However, due to varying scheduling demand, an hour long intake session may not always be available within the time frame needed by some patients. 

We understand that some patients may prefer to be seen sooner due to low stock of their current medication supply. 

If an hour long intake session is not available right away and you are open to a shorter 30-minute intake session, we may be able to schedule you sooner. 

 As long as all required intake forms and policy documents are completed and it is clinically appropriate, we may offer a short-term medication refill at this visit if your current supply is running low.
Are you open to a 30-minute brief intake session if it allows for an earlier appointment?
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Please share how we can help you *
How did you hear about us? *
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