Get Started
Step 1 of 4
Have you ever been diagnosed with major depression?
*
Have you ever been diagnosed or treated for bipolar disorder, schizoaffective disorder, or schizophrenia?
*
Do you have a metal implant in or around the head? (aneurysm coil or clip, metal plate, ocular implant, stent)
*
Do you have cerebrovascular disease, dementia, history of severe head trauma, increased intracranial pressure, or primary or secondary tumors in the central nervous system?
*
Do you have a seizure disorder/epilepsy?
*
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Step 2 of 4
Over the past 2 weeks, how often have you noticed any of the following symptoms?
0 (Not at all), 1 (Several days), 2 (More than half the days), 3 (Nearly every day)
Little interest or pleasure in doing things?
*
0
1
2
3
Feeling down, depressed, or hopeless?
*
0
1
2
3
Trouble falling asleep, staying asleep, or sleeping too much?
*
0
1
2
3
Feeling tired or having little energy?
*
0
1
2
3
Poor appetite or overeating?
*
0
1
2
3
Little interest or pleasure in doing things?
*
Never
0
1
2
Nearly Every Day
3
0 is Never, 3 is Nearly Every Day
Feeling down, depressed, or hopeless?
*
Never
0
1
2
Nearly Every Day
3
0 is Never, 3 is Nearly Every Day
Trouble falling asleep, staying asleep, or sleeping too much?
*
Never
0
1
2
Nearly Every Day
3
0 is Never, 3 is Nearly Every Day
Feeling tired or having little energy?
*
Never
0
1
2
Nearly Every Day
3
0 is Never, 3 is Nearly Every Day
Poor appetite or overeating?
*
Never
0
1
2
Nearly Every Day
3
0 is Never, 3 is Nearly Every Day
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Next
Step 3 of 4
0 (Not at all), 1 (Several days), 2 (More than half the days), 3 (Nearly every day)
Feeling bad about yourself, that you're a failure, or have let someone down?
*
0
1
2
3
Trouble concentrating or focusing on things?
*
0
1
2
3
Moving/speaking more slowly? Or being more fidgety/restless than usual?
*
0
1
2
3
Thoughts that you would be better off dead or hurting yourself in some way?
*
0
1
2
3
Feeling bad about yourself, that you're a failure, or have let someone down?
*
Never
0
1
2
Nearly Every Day
3
0 is Never, 3 is Nearly Every Day
Trouble concentrating or focusing on things?
*
Never
0
1
2
Nearly Every Day
3
0 is Never, 3 is Nearly Every Day
Moving/speaking more slowly? Or being more fidgety/restless than usual?
*
Never
0
1
2
Nearly Every Day
3
0 is Never, 3 is Nearly Every Day
Thoughts that you would be better off dead or hurting yourself in some way?
*
Never
0
1
2
Nearly Every Day
3
0 is Never, 3 is Nearly Every Day
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Final Step
Who is your insurance carrier?
*
Please Select
Aetna
Blue Cross Blue Shield Anthem
BlueCross/BlueShield FEP (Federal Employee Plan)
Blue Cross Blue Shield Regence
Blue Cross Blue Shield Other Plan
Cigna
First Choice Health
MODA (formerly ODS)
OHP/Medicaid
Optum
PacificSource Commercial Plan
PacificSource Community Solutions (OHP Plan)
Providence
Tricare
UnitedHealthcare
Medicare
Other
None
Which OHP partner is your plan with?
Please Select
AllCare Health Plan
Cascade Health Alliance
Columbia Pacific Coordinated Care Organization
Eastern Oregon Coordinated Care Organization
FamilyCare, Inc.
Health Share of Oregon
Intercommunity Health Network Coordinated Care Organization
Jackson Care Connect
Pacific Community Solutions Coordinated Care Organization, Columbia Gorge Region
Pacific Source Community Solutions Coordinated Care Organization, Central Oregon Region
PrimaryHealth of Josephine County, LLC
Trillium Community Health Plan
Umpqua Health Alliance
Western Oregon Advanced Health, LLC
Willamette Valley Community Health, LLC
Yamhill Community Care Organization
How many antidepressants have you tried?
*
0
1
2
3
4 or more
How many antidepressants have you tried?
*
None
0
1
2
3
4 or more
4
0 is None, 4 is 4 or more
Have you been through counseling or psychotherapy?
*
Have you had a previously successful trial or TMS Therapy?
*
Contact Details
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Your Name
*
E-mail
*
Phone Number
*
Best time to call:
*
Early Morning
Late Morning
Early Afternoon
Late Afternoon
Anytime
Other
How did you hear about us?
*
Please Select
Commercial
Facebook
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Family/Friend
Medical Provider
Other
Additional comments (optional)
*
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