Client Intel Sheet

Client Intel Sheet

Info we need to get started!
- Please fill out the form completely.
- You can save your progress at the bottom of the page.
- You will be able to book your Kickoff meeting upon completion.
- This form is required in order to reach your desired Launch date.
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Your Name*

First NameLast Name
Your Email*
example@example.com
Which Tier did you sign up for?*
Please choose the plan you signed up for (refer to contract if uncertain)
Did you sign up for our Appointment Booking program?*
Please refer to the contract if uncertain.
Practice Information
Practice Name*
Exactly as you'd like it to appear
Existing Website*
Provide the link to your website
Practice Phone*
Main Office Number
Practice Email
For general office emails, leave blank if not applicable
Time Zone*
i.e. PST, CST, EST
Preferred Area Code*
For the tracking phone number we create for you
Legal Business Name*
*Must match your EIN assignment letter from the IRS*
Legal Business Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Billing Tax ID (EIN)*
Needed in order to send texts and ad platform verification
Business Type*
i.e. LLC, PC, PLLC, Sole Proprietorship
Example of EIN assignment letter (CP-575)

We need a copy of this document for Google Ads verification
Please upload a copy of your EIN assignment letter from the IRS (CP-575)*

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Needed for Google Ads verification Cancelof
Please provide us a copy/picture of front and back of owner's drivers license*

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Needed for Google Ads verification Cancelof
List all in-network insurances*
These will be displayed on your landing pages
Please provide photos of your office (Exterior, lobby, treatment room, etc.)

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This could significantly improve your SEO value and ad performance Cancelof
Client Information
Primary Administrator*

First NameLast Name
Primary Administrator's Email*
This will be your first APP4TMS user. You can add more users once you log in.
Practice Owner(s)*
Please list first and last name of owner(s)
Practice Owner's Email*
Choose one email for internal use only, billing/account questions
Practice Owner's Phone*
Choose one phone for internal use only, billing/account questions
Appointment Booking Info
Group NPI*
Rendering Provider NPI*
Which NPI is TMS billed under?*

Group NPIRendering Provider NPIOther
Insurance Rates for each insurance and each code*

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Please upload CSV, spreadsheet, or document below Cancelof
Upload contracts for each in-network insurance*

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We need to verify the codes are billable with the billing NPI Cancelof
What are your Cash Pay rates for each protocol you offer?*
Please specify specific rates for each TMS treatment option you offer
Please provide all payment options provided*
For patients that are out-of-network or need financial assistance
Please list all off-label or non-standard TMS protocols you offer
Leave blank if not applicable
Is the provider willing to see TMS patients with a previous diagnosis of Bipolar or substance use?*

Yes, book eitherOnly BipolarOnly Substance useNeitherOther
Please specify any other details or requirements related to pre-screening patients.
Be as specific as possible so our team can pre-screen appropriately
Which phone number should our team refer non-TMS patients to?*
Please provide a phone number below
Do you offer in-person evaluations, Telehealth, or both?*

In-person onlyTelehealth onlyOpen to bothOther
What is your meeting link for Telehealth appointments?
If each meeting link is unique then please explain
What is your set availability for TMS evaluations?*
Appointment Booking requires at least 4 recurrent 1-hour slots per week
Basic Tier

Here's what we need
Essentials Tier

Here's what we need
Master Tier

Here's what we need
Which service have you elected to run campaigns for?*

TMSSpravatoIV KetamineMedication ManagementTherapyPsychadelicsOther
Which service(s) have you elected to run campaigns for?*

TMSIV KetamineSpravatoMedication ManagementTherapyPsychedelicsOther
Do you have any notes or preferences regarding geographic location targeting?
This is for the marketing campaigns, our standard is typically a 15-20 mile radius around the clinic
Who will be the primary lead manager?*
Please name the person who will be reaching out to leads
Primary Lead Manager's Role
If unsure, type TMS Coordinator
Primary Lead Manager's Email*
example@example.com
How would you like to be notified of a new lead? Select all that apply*

App (required)EmailSMSOther
Provide the phone number(s) for SMS notifications*
Enter a cell phone number below to receive texts
Provide the email(s) for email notifications*
Enter an email address below
When a TMS lead calls, which phone should ring?*

Main Office PhoneOwner's PhonePrimary Administrator's PhoneOnly through APP4TMSOther
Which patient scale(s) do you prefer?

PHQ-9PHQ-9 and GAD-7PHQ-9 and HAM-AOther
Please list any additional emails of users you'd like added to your Slack support channel
Other than the ones you have already mentioned
Which TMS device(s) do you use? Select all that apply*

BrainsWayMagstimMagVentureNeurostarNexstimApollo TMSCloud TMSBlossom TMSMagnus MedicalOther
How did you hear about us?
Let us know if you were referred!
Now it's time to book your Kickoff Meeting

You will be redirected to book your Kickoff after submitting this form
Any additional notes before you book your Kick-Off Meeting?
Click Submit to redirect to the booking page
Should be Empty:

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Practice Information

Example of EIN assignment letter (CP-575)

Client Information

Appointment Booking Info

Basic Tier

Essentials Tier

Master Tier

Now it's time to book your Kickoff Meeting