TMS External Referral form 2026

TMS EXTERNAL REFERRAL FORM

Outpatient Clinic
IF THE PATIENT IS EXPERIENCING A MEDICAL OR PSYCHIATRIC EMERGENCY, DO NOT FILL OUT THIS FORM. INSTEAD CALL 911, GO TO THE NEAREST ED, OR CALL 988 FOR ADDITIONAL CRISIS RESOURCES.
Name

Legal First NameLegal Last Name
Date of Birth

MonthDayYear
Date
Previous Names Used
Preferred Name
Social Security #
Guardian Conservator If Applicable
Mailing Address
Street Address if different
City
State
Zip Code
*Phone #
Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact
May we leave a message with patient information on the preferred phone # above?
INSURANCE INFORMATION
Primary Insurance
Primary Insured Party Name
DOB
Relationship to Patient
Policy
Group
Effective Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
CRITERIA AND HISTORY

(For appropriateness and authorization)
Please enter any information you have about specific medication trial including dates, dosages, and responses that may be relevant to obtaining authorization for TMS treatment:
Diagnosis (this is relevant to this referral). Note: Medicare and most private insurers restrict TMS treatment to diagnoses of Major Depressive Disorder, severe. If bipolar disorder is the current diagnosis, please explain the depressive presentation in this referral.
Does client meet criteria for treatment resistant depression as defined by CMS? (four medication trials in two categories):
Evidence-based psychotherapy for depression:
Please describe any history or hospitalization and how recent
Has the patient ever had ECT?
Additional information that would be helpful to know about this referral?
REFERRING PROVIDER INFORMATION
Referred by
Practice Name
Email address of referring provider
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
File Upload

Cancelof
To fully process this referral, please fax (802)258-3788 or email outpatient@brattlebororetreat.org a copy of:

1) Most recent medical note

2) Medication history

3) Front and back of the individual's insurance card.

Should there be any required information missing, a Practice Management Team member will reach out within 24 business hours to gather the information prior to being able to process the referral.
Should be Empty:

CRITERIA AND HISTORY