TMS Intake Survey

  • TMS & Spravato Intake Survey

    Updated September 2026

  • We're glad you're interested! TMS and Spravato are two of the most exciting treatments available. We'd love to get to know you a little better. 

  • Date of Birth*
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  • Emergency Contact Relationship (Please pick the one that best represents the relationship to the patient)*

  • Past Diagnoses

  • Are you willing to get treatment in person?
  • How did you hear about us?

  • Over the last 2 weeks, how often have you been bothered by any of the following problems?

  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless?
  • Trouble falling/staying asleep, sleeping too much
  • Feeling tired or having little energy?
  • Poor appetite or overeating?
  • Feeling bad about yourself — or that you are a failure or have let yourself or your family down?
  • Trouble concentrating on things, such as reading the newspaper or watching television?
  • Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
  • Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?
  • Feeling nervous, anxious, or on edge?
  • Not being able to stop or control worrying?
  • Worrying too much about different things?
  • Trouble relaxing?
  • Being so restless that it's hard to sit still?
  • Becoming easily annoyed or irritable?
  • Feeling afraid as if something awful might happen?

  • Other Providers

    Great job so far! This next section is lets us know a bit more about your past providers. As with all sections, the more information you share, the better and faster we can answer your questions, but it is not required.
  • Have you seen a therapist / counselor in the last few years?
  • Do you have a current or recent psychiatrist (MD who prescribes meds)?
  • Do you have a current or recent primary care provider?
  • If you plan to get fMRI neuro-navigated treatment, we need to communicate your information to our partners who perform the scans. We will not communicate any information except after we've verbally discussed it. If you decline now and decide to proceed with treatment, we will have to separately contact you to get written consent and this may slow the process. May Acacia Mental Health communicate about your medical and mental health care with our partnered imaging centers for the purposes of obtaining scans: El Camino Hospital and/or Medical Imaging Center of Southern California?
  • Often it's very helpful in giving you the best care for your providers to communicate and collaborate. We'd love to be able to understand as much as we can about what you've been through and the perspectives of your other doctors / providers, including information about your mental health. May Acacia Mental Health obtain information about your past care from the providers you listed above?
  • If we do treat you, it is often also helpful to communicate with your providers moving forward. May Acacia Mental Health communicate about your medical and mental health care with the providers listed above?
  • Have you tried TMS (Transcranial Magnetic Stimulation)? If so, did it work?
  • Have you tried ECT (Electro-Convulsive Therapy)? If so, did it work?
  • Have you tried IV Ketamine or Spravato Therapy? If so, did it work?
  • Have you been hospitalized because of mental health challenges within the past 90 days?
  • How strongly do you agree or disagree with the following statement:  "My mental/psychiatric symptoms are so severe, I might need to go to this hospital this week."

  • Medications

    Great job so far! This next section is lets us know a bit more about your past providers. Next, we'll ask you more about your past medications.

  • Medication #1

    The following questions will be about the medication you started MOST RECENTLY.
  • Is this a current medication?

  • Medication #2

    The following questions will be about the medication you started second-most recently.
  • Is this a current medication?

  • Medication #3

    The following questions will be about the medication you started second-most recently.
  • Is this a current medication?

  • Medication #4

    The following questions will be about the medication you started second-most recently.
  • Is this a current medication?

  • Medication #5

    The following questions will be about the medication you started second-most recently.
  • Is this a current medication?

  • Medication #6

    The following questions will be about the medication you started second-most recently.
  • Is this a current medication?
  • Are you currently taking a benzodiazepine like lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax), or diazepam (Valium)?
  • What benzodiazepine are you taking?

  • Do you have any allergies to medications, including prescription drugs, over-the-counter medications, or supplements?
  • Have you ever had a severe allergic reaction (e.g. anaphylaxis) requiring emergency treatment?
  • Have you had any of the following (even once)? These are not necessary rule-outs for TMS.
  • Which of the following best describes how much you drink alcohol?
  • Which of the following best describes how often you consume cannabis?
  • Which of the following best describes how often you use other "hard" drugs (hallucinogens, meth, heroin, etc.)?

  • Financial Information

  • While we would like to focus on the clinical aspects of care, we realize that finances can be a barrier. In order to minimize delays in care, we give you the option of giving insurance information.

  • What best describes who will be paying for treatment or copays?

  • Acacia offers many types of TMS.  Our physicians can provide more information to help determine the best option for you.  Many people want to ask about pricing prior to speaking to one of our physicians.  The easiest way to understand pricing is in terms of acceleration.  Conventional TMS is one treatment per day.  If you qualify, your insurance company may subsidize part or all of the once a day treatments.  Accelerated TMS is much faster and involves up to ten treatments per day (e.g. Acacia's HOPE-TMS, Stanford's SAINT protocols).  Accelerated TMS is not yet covered by most insurances. Our pricing for accelerated TMS starts at $25,000 but may decrease based upon financial need.  If you are interested in HOPE-TMS (Neuronavigated Targeting based on an fMRI), there is an additional cost of $6,000 to $14,000 depending upon where the fMRI is conducted. If you have more questions regarding TMS pricing, we encourage you to ask one of our physicians.

  • Please select which option that BEST reflects your interests right now.
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  • For Accelerated TMS - If cost would prohibit you from seeking accelerated TMS treatment would you be willing to complete a separate financial aid request form and provide supporting financial information? (Financial aid MAY be awarded for family income less than $300,000 per year PLUS other financial considerations. However, financial aid is not guaranteed)

  • Please answer the following questions for the household financially responsible for you (e.g. if a spouse financially supports you, please answer for your hosehold; if you parents support you, please answer for them). Approximations on the following numbers are acceptable. We may request documentation (e.g. IRS 1040 from a previous year) to verify these numbers.

  • Do you have insurance?

  • If you have selected "Yes, I have insurance coverage at this time", please upload your insurance information below: 

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  • Acacia submits all claims for Doctor Visits (e.g. Intake Process and During Treatment) to insurance when possible.

    We hope to provide compassionate, conscious care for those in need. 

     

    We look forward to seeing how we can best help! 

     

  • Last Page - Policies and Privacy (Please Submit at the end)

  • Date Patient Policies Signed*
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  • Date HIPAA Privacy Policies Signed*
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