This form and all information contained therein are HIPAA compliant.
Full Name
*
Email
*
example@example.com
Phone Number
*
555-555-5555
Who is seeking treatment?
*
Me
Someone I care about
Please check all that apply:
*
I have had TMS treatment before.
I am currently struggling with depression.
I have tried multiple antidepressants
I have tried talk therapy for depression.
I DO NOT have metal above my shoulders (excluding dental work), such as implants, shrapnel, surgical clips, or stents.
I HAVE NOT been diagnosed with schizophrenia or psychosis.
I DO NOT have a history of seizures.
What health insurance carrier do you have? If you do not have insurance, please write "self-pay".
*
If you have secondary insurance, please list the carrier below.
What is your preferred contact method?
*
Email
Phone
Is there anything else you would like us to know?
Submit
Should be Empty: