RVTMS - 09/2023 Self Assessment

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TAKE THE TMS SELF-ASSESSMENT

TAKE THE TMS SELF-ASSESSMENT

There is always hope for recovery from depression! Take the self-assessment to find out if TMS is right for you. Your responses and info will remain confidential.

8Questions

HIPAA

Compliance

1
How many antidepressants have you tried?* This field is required.
0
1
2
3
4
None
4 or more
2
Have you ever been diagnosed with major depression?* This field is required.
YESNO
3
Have you ever been diagnosed with OCD?* This field is required.
YESNO
4
Your Name* This field is required.
5
Phone Number* This field is required.
6
E-mail* This field is required.
7
When is the best time to reach you?* This field is required.
Early Morning
Late Morning
Early Afternoon
Late Afternoon
Anytime
Other
8
Who is your insurance carrier?* This field is required.This is the last question. After this, you'll be redirected to a message confirming that your assessment has been received.
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
9
* This field is required.
10
Unique ID
Should be Empty:

Question Label

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