TMS Self-Assessment Test

This is a secure form. Your information is kept confidential and will never be shared or sold to third parties. It will only be used to assess whether TMS is a suitable option for you.

We look forward to assisting you! Please finish filling out the form, and we will reach out with more details shortly.

Please Note: Our TMS clinics are located within the Chicagoland area.

Are you based in the state of Illinois?*

YesNo

What is your preferred Clarity Clinic TMS location?*

Chicago Loop - 333 N. Michigan AveArlington Heights - 2101 S. Arlington Heights Rd

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Best Time to Call:

Date of Birth:*

Date of Birth

Fell free to share any additional information about what you've been experiencing:

Please verify that you are human*