Sunrise Psychiatry - Self Assessment Form

1

This assessment is meant to help identify if TMS is right for you. For more accurate results we recommend calling our office or scheduling a call, otherwise you may continue to assessment.Office: 913-333-0448

Schedule a CallContinue to Assessment

2

Do any of the following statements apply for you?

Have a tumor or space-occupying lesion in your brain

Have a pacemaker

Have an implant near or around your heart or brain

Have a cerebral shunt

None of the above

3

Has any physician, nurse practitioner or psychotherapist ever diagnosed you with bipolar disorder?* This field is required.

YESNO

4

Have you been diagnosed with any of the following?

Epilepsy

Schizoaffective Disorder

Schizophrenia

None of the above

5

Over the last two weeks, how often have you felt down, depressed, or hopeless?* This field is required.

0 (Not at all)

1 (Several days)

2 (More than half the days)

3 (Nearly every day)

6

Over the last two weeks, how often have you felt tired or had little energy?* This field is required.

0 (Not at all)

1 (Several days)

2 (More than half the days)

3 (Nearly every day)

7

Over the last two weeks, how often have you felt bad about yourself, that you're a failure, or have let someone down?* This field is required.

0 (Not at all)

1 (Several days)

2 (More than half the days)

3 (Nearly every day)

8

Over the last two weeks, how often have you had thoughts that you would be better off dead or hurting yourself in some way?* This field is required.

0 (Not at all)

1 (Several days)

2 (More than half the days)

3 (Nearly every day)

9

Are you interested in using insurance to cover TMS Therapy?* This field is required.TMS is now FDA-approved for the treatment of depression in children ages 15-17 but is NOT covered by insurance. If you are still interested select "Yes" otherwise select "No".

YESNO

10

How would you like to get in touch?

Schedule a CallLet Our Staff Reach Out

11

You may be a good candidate for treatment at Sunrise Psychiatry!* This field is required.Please provide some basic information to allow our staff to get in contact with you regarding your interest in TMS

First Name

Last Name

12

Phone Number* This field is required.

Please enter a valid phone number.

13

Email* This field is required.

example@example.com

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When is the best time to reach you?* This field is required.Please select all that apply.

Early Morning

Late Morning

Early Afternoon

Late Afternoon