Vital TMS Therapy & Mental Health Services
TMS Intake Form
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Email Address
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
*
Please Select
Psychiatrist or Nurse Practitioner
Family Doctor or Nurse Practitioner
Therapist
Current or Former Patient
Google Search
Facebook
Psychology Today
Instagram
A loved one
Insurance Company
Intensive Outpatient Program
Behavioral Health Hospital
Veterans Affairs
Community Event
Other
Other:
Please specify, it helps us, help more people!
Gender Identity: (Optional)
Preferred Pronouns (Optional)
Sexual Orientation (Optional)
Ethnicity (Optional)
Marital Status (Optional)
Emergency Contact Person
Emergency Contact Person Phone #
Current Primary Care Doctor's Name
Current Primary Care Doctor's Phone #
Current Mental Health Clinician's Name
i.e. Phsychiatrist, Mental Health Nurse Practioner
Current Mental Health Clinician Phone #
Current Therapist's Name
i.e. Psychologist, Counselor / Social Worker/ LiCSW or PHD
Current Therapist Phone #
INSURANCE INFORMATION
Primary Insurance Company Name
*
Insurance Policy or Member ID Number
*
Primary Insurance Group Number
Are you the policy holder?
*
Please Select
Yes
No
Policy Holder's Name
Policy Holder's Address
Policy Holder's Date of Birth
Your Relationship to the Policy Holder?
Child, Husband, Wife, Partner, Other
Do you have a secondary insurance?
*
Please Select
Yes
No
Secondary Insurance Company Name
Secondary Insurance Company Phone #
Are you enrolled in the Medicare program?
Please Select
Yes
No
Are you enrolled in the Medicaid program?
Please Select
Yes
No
Are you enrolled in the Veteran's Affairs (VA) program?
Please Select
Yes
No
Mental Health History
Please complete the following information and our team will go through this in more detail with you at your TMS consultation.
Approximately when did your current depressive symptoms start?
Do you have any previous mental health hospitalizations?
Please Select
Yes
No
What was the approximate date of your most recent mental health hospitalization?
How many mental health hospitalizations have you had?
Please Select
1
2
3
4
5 or more
Are you CURRENTLY under the care of a Psychiatrist or Psychiatric Nurse Practioner who prescribes you medication?
Please Select
Yes
No
In the past, have you attended talk therapy with a therapist, counselor or Psychologist?
Please Select
Yes
No
Do you CURRENTLY attend talk therapy with a therapist, counselor or Psychologist?
Please Select
Yes
No
What is the approximate date that you last attended talk therapy?
Please Select ALL of your Current Symptoms
Depressed Mood
Low Energy
Suicidal Thoughts
Self-Injurious Behavior
Self-Injurious Thoughts
Increased Appetite
Decreased Appetite
Restlessness
Sleep Disturbance
Impaired Concentration
Fatigue
Low Motivation
Memory Deficits
Excessive Worry
Panic attacks
Talking or moving slowly
Nightmares
Decreased need for sleep
Physical Pain
Difficulty relaxing
Intrusive / unwanted thoughts
Excessive Alcohol Use
Drug Abuse
Illicit Drug Use
Anorexia
Bulimia
Elevated or Euphoric Mood
Confusion
Muscle Tension
Social Anxiety
Ritualistic Behaviors
Isolation
Decreased Hygiene
Hearing voices or noises others can't hear
Homicidal thoughts
Upset stomach / Nausea
Inability to work
Binge eating
Seeing people or things that others can't see
Flashbacks
Excessive energy
Pertinent Medical History
Do you have any metal objects or implantable devices in or around the head (e.g. cardiac defibrillator / pacemaker, cochlear impant, other)?
Please Select
Yes
No
Unsure
If "YES" or "UNSURE" to the presence of metal objects or devices, please provide as much detail as possible in the space provided below:
Do you have any History of Seizures?
Please Select
Yes
No
If "YES" or "UNSURE" to the presence of metal objects or devices, have you had an MRI in the past and is it safe for you to have a MRI now?
Please Select
Yes
No
Unsure
Please bring your impant card with you to the consultation, if you have it.
Do you have any Allergies?
Please Select
Yes
No
If "YES" to allergies, please list them and the reaction( i.e penicillin gives me a rash) :
Please list ALL of your Medical Diagnoses:
Please list ALL previous surgeries with the year the surgery was performed.
Family History
Do you have a family history of mental health issues?
Please list the family member(s) and the disorder(s)
Social History
Do you live alone or with others
Please Select
Alone
With Others
If you live with others, who do you live with?
What is your occupation?
Employment Status?
Have you ever smoked cigarettes?
Please Select
Yes
No
Currently?
Please Select
Yes
No
How many packs per day?
How many years?
In the Past?
Please Select
Yes
No
How many packs per day?
How many years?
When did you quit?
Vaping?
Please Select
Yes
No
Marijuana?
Please Select
Yes
No
If yes, How often?
Alcohol?
Please Select
Yes
No
If yes, How often and how much?
Illicit drug use?
Please Select
Yes
No
Have you ever considered yourself to have a problem with alcohol or drugs?
Please Select
Yes
No
If yes, approximately how long has it been since you last used alcohol or drugs?
Antidepressants
Carefully examine the list below, please select both CURRENT and PREVIOUS medications tried:
SSRI's
*
Prozac (fluoxetine)
Celexa (citalopram)
Luvox (fluvoxamine)
Zoloft (sertraline)
Paxil (paroxetine)
Lexapro (escitalopram)
None
Please include the Dosage and timeframes for the option(s) selected
SNRI's
*
Pristiq (desvenlafaxine)
Effexor (venlafaxine)
Fetzima (levomilnacipran)
Cymbalta (duloxetine)
Savella (milnacipran)
None
Please include the Dosage and timeframes for the option(s) selected
TCA's
*
Tofranil (imipramine)
Vivactil (protriptyline)
Elavil (amitriptyline)
Pamelor (nortriptyline)
Anafranil (clomipramine)
Doxepin (sinequan)
Norpramin (desipramine)
None
Please include the Dosage and timeframes for the option(s) selected
MAOI's
*
Marplan (isocarboxazid)
Parnate (tranylcypromine)
Emsam (selegiline)
Nardil (penelzine)
None
Please include the Dosage and timeframes for the option(s) selected
NDRI
*
Wellbutrin (bupropion)
None
Please include the Dosage and timeframes for the option(s) selected
SM's
*
Viibryd (vilazodone)
Deseryl / Oleptro (trazodone)
Serzone (nefazodone)
Trintellix (vortioxetine)
None
Please include the Dosage and timeframes for the option(s) selected
Other antidepressants
*
Spravato (esketamine)
Auvelity (dextromethorphan & bupropion
Ketamine
Desyrel / Oleptro (trazodone)
None
Please include the Dosage and timeframes for the option(s) selected
Mood Stabilizers
*
Tegretol (carbamazepine)
Depakote (valproate)
Trileptal (oxcarbamazepine)
Lithium
Lamictal (lamotrigine)
Topax (topiramate)
None
Please include the Dosage and timeframes for the option(s) selected
Anti-Psychotics / Mood Stabilizers
*
Seroquel (quetiapine)
Abilify (aripiprazole)
Clozaril (clozapine)
Prolixin (fluphenazine)
Latuda (lurasidone)
Rexulti (brexpiprazule)
Vraylar (cariprazine)
Geodon (ziprasidone)
Zyprexa (olanzapine)
Haldol (haloperidone)
Invega (paliperidone)
Risperdal (risperidone)
Caplyta (lumateperone)
None
Please include the Dosage and timeframes for the option(s) selected
Sedative / Hypnotics
*
Ambien (zolpidem)
Rozerem (ramelteon)
Sonata (zaleplon)
Restoril (temazepam)
None
Please include the Dosage and timeframes for the option(s) selected
ADHD / Stimulants
*
Adderall (amphetamine salts)
Strattera (atomoxetine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Vyvanse (dextroamphetamine)
None
Please include the Dosage and timeframes for the option(s) selected
Anti Anxiety
*
Xanax (alprazolam)
Klonopin (clonazepam)
Tranxene (clorazepate)
Ativan (lorazepam)
Valium (diazepam)
BuSpar (buspirone)
None
Please include the Dosage and timeframes for the option(s) selected
Please list any other medications not on this list:
PHQ-9
Patient Health Questionnaire-9- Self Rating Scale
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest of pleasure in doing things
*
Not at all
Several days
More than half the days
Nearly every day
2. Feeling down, depressed or hopeless
*
Not at all
Several days
More than half the days
Nearly every day
3. Trouble falling or staying asleep, sleeping too much
*
Not at all
Several days
More than half the days
Nearly every day
4. Feeling tired of having little energy
*
Not at all
Several days
More than half the days
Nearly every day
5. Poor appetite or overeating
*
Not at all
Several days
More than half the days
Nearly every day
6. Feel bad about yourself or that you are a failure or have let yourself or your family down
*
Not at all
Several days
More than half the days
Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
Several days
More than half the days
Nearly every day
8. Moving or speaking so slowly that other people could have noticed. Or the opposite- being so figety or resltess that you have been moving around a lot more than usual.
*
Not at all
Several days
More than half the days
Nearly every day
9. Thoughts that you would be better off dead, or of hurting yourself
*
Not at all
Several days
More than half the days
Nearly every day
If you check off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not Difficult at all
Somewhat Difficult
Very Difficult
Extremely Difficult
Result (office use only)
GAD-7
Generalized Anxiety Disorder -7- Self Rating Scale
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Feeling nervous, anxious, or on edge
*
Not at all
Several days
More than half the days
Nearly every day
2. Not being able to stop or control worrying
*
Not at all
Several days
More than half the days
Nearly every day
3. Worrying too much or about different things
*
Not at all
Several days
More than half the days
Nearly every day
4. Trouble relaxing
*
Not at all
Several days
More than half the days
Nearly every day
5. Being so restless that it is hard to sit still
*
Not at all
Several days
More than half the days
Nearly every day
6. Becoming easily annoyed or irritable
*
Not at all
Several days
More than half the days
Nearly every day
7. Feeling afraid as if something awful might happen
*
Not at all
Several days
More than half the days
Nearly every day
If you check off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not Difficult at all
Somewhat Difficult
Very Difficult
Extremely Difficult
Result (office use only)
Signature
*
Date
*
-
Month
-
Day
Year
Date
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