TMS Therapy Patient Intake Assessment
Welcome to TMS Therapy this quick assessment takes about 2 minutes. Your information is protected under HIPAA and will only be used to assess your eligibility and contact you about treatment..
Privacy & Consent Agreement
*
I acknowledge the privacy notice above and consent to the collection and use of my health information.
What condition are you seeking help for?
*
Depression
Anxiety
OCD(Obsessive Compulsive Disorder)
PTSD(Post Traumatic Stress Disorder)
Other
What type of TMS therapy are you interested in?
*
Daily TMS
Accelerated TMS
Not sure
What type of TMS therapy are you interested in?
*
Daily TMS
Accelerated TMS
Not sure
Over the past 2 weeks, how often have you been bothered by the following?
*
Rows
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Over the past 2 weeks, how often have you been bothered by the following?
*
Rows
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious, or on edge?
Not being able to stop or control worrying?
How much time do your obsessive thoughts and compulsive behaviors occupy each day?
*
Less than 1 hour
1-3 hours
3-8 hours
More than 8 hours
In the past month, how much have you been bothered by repeated, disturbing memories, thoughts, or images of the stressful experience?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
How long have you been experiencing these symptoms?
*
Less than 6 months
6 to 12 months
More than 12 months
What treatments have you tried? (Select all that apply)
Antidepressant medications (e.g., Zoloft, Lexapro, Prozac)
Anti-anxiety medications (e.g., Xanax, Ativan, Buspar)
Talk therapy / Counseling
Cognitive Behavioral Therapy (CBT)
Other treatments
None of the above
Are you currently taking psychiatric medication?
*
Yes
No
Do you have health insurance you'd like to use?
*
Yes
No
Insurance Provider
Please Select
Aetna
Cigna
Medicare
United Healthcare
Blue Cross blue shield
Other
Please specify your insurance Provider.
*
What is your ZIP code?
Example 85XX
When would you like to start treatment?
*
As soon as possible
Within the next 30 days
I'm just gathering information for now
Contact Information
*
First Name
Last Name
Email
*
example@example.com
Preferred Contact Method
*
Phone Call
Text
Email
Any
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Were you referred by a healthcare provider?
Yes
No
Referring Provider's Name.
Provider's Specialty.
Clinic/Practice Name.
Provider's Email (for referral confirmation)
Submit
Should be Empty: