TMS Consultation Intake

1

Personal Info

Full Name (first, last)

Birthdate (MM/DD/YYYY)

Age

Address

Please enter your phone

City

ZIP code

2

EmailPlease enter your email

example@example.com

Confirm Email

3

Who is your Therapist/Psychiatrist

Who is your Psychiatrist

who is your Therapist

5

The TMS Therapy procedure and your depression Why are you considering TMS Therapy now?

6

Medicationsplease list any medication you have used in the past or currently

Medication name and Amount (Mg)

START DATE/END DATE

Medication name and Amount (Mg)

START DATE/END DATE

Medication name and Amount (Mg)

START DATE/END DATE

Medication name and Amount (Mg)

START DATE/END DATE

7

Are you currently taking or have taken any medication for a seizure disorder

YESNO

8

If answered YES on previous question, please list medication(s)

Medication

START DATE

END DATE

9

Insurance Provider Information

Insurance Provider name

Group Number

ID Number

10

Assessment Details

Assessment Taken by

Assessment Date