Appointment Request / Insurance Check

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Date

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Free New Client Initial Consult

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Myself

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Patient's Date of Birth* This field is required.

Date

Patient's Name* This field is required.

First Name

Last Name

Patient's Gender

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Female

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What is Your Name?* This field is required.

Your First Name:

Your Last Name:

What is Your Email?* This field is required.

example@example.com

Your Phone Number Which Can Receive Texts:* This field is required.

Best number to reach you during business hours (we will not contact you other than for appointment reminders or to answer your questions):

In which of our offices would you like to receive our services?* This field is required.Some services are offered at home, but at least one office visit is required.

Modesto

San Jose

San Ramon

Some of our services, such as neurofeedback, auditory integration training, and cognitive rehabilitation training, are available at home (none are covered by insurance), but at least one office visit is required.

TMS services are in-office only.

Let's Figure Out the Distance and Your Travel Time First

Your ZIP code and press ENTER:* This field is required.Let's find out the distance and your travel time.

Your ZIP code and press ENTER::* This field is required.Let's find out the distance and your travel time.

We are too far away to offer you a free appointment. We offer a 25-minute paid consultation for $195, which will be credited towards any services you use within one year.

Yes

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I am interested in finding out more about:* This field is required.

I am not sure

Functional qEEG Brain Mapping [We Do Not Accept Insurance For This Service]

TMS

Neurofeedback [We Do Not Accept Insurance For This Service]

Auditory Training [We Do Not Accept Insurance For This Service]

tDCS [We Do Not Accept Insurance For This Service]

Near Infrared Light Therapy [We Do Not Accept Insurance For This Service]

Focused Ultra-Sound Therapy [We Do Not Accept Insurance For This Service]

Full Diagnostic Evaluation [We Do Not Accept Insurance For This Service]

My challenges are:* This field is required.

Depression

Bipolar

Anxiety

OCD

ADHD [We Do Not Accept Insurance For This Service]

Autism [We Do Not Accept Insurance For This Service]

Asperger’s [We Do Not Accept Insurance For This Service]

Auditory Processing Disorder [We Do Not Accept Insurance For This Service]

Dyslexia [We Do Not Accept Insurance For This Service]

Learning Disorder [We Do Not Accept Insurance For This Service]

Developmental Delays [We Do Not Accept Insurance For This Service]

Addiction [We Do Not Accept Insurance For This Service]

Brain Injury / Brain Fog [We Do Not Accept Insurance For This Service]

Postconcussive Syndrome (PCS) [We Do Not Accept Insurance For This Service]

Chronic Pain [We Do Not Accept Insurance For This Service]

Insomnia- Sleep-Related Issues [We Do Not Accept Insurance For This Service]

Memory [We Do Not Accept Insurance For This Service]

PTSD [We Do Not Accept Insurance For This Service]

Tinnitus [We Do Not Accept Insurance For This Service]

Other

Have you ever taken any Antidepressants (even for few days) ?* This field is required.This might help with possible Insurance approval

Yes

Select any of these medications you have used in the past or are now taking.* This field is required.Even if for one day

Celexa/Citalopram

Cymbalta/Duloxetine

Effexor/Venlafaxine

Elavil/Amitriptyline

Fetzima

Lexapro/Escitalopram

Luvox/Fluvoxamine

Nardil /Phenelzine

Norpramin/Desipramine

Pamelor/Nortriptyline

Parnate/Tranylcypromine

Paxil/Paroxetine

Pristiq/Desvenlafaxine

Prozac/Fluoxetine

Remeron/Mirtazapine

Tofranil/Imipramine

Trintellix

Viibryd/Vilazodone

Vivactil/Protriptyline

Wellbutrin/Bupropion

Zoloft/Sertraline

Other

Calculation of how many antidepressants taken

Who is your insurance provider?* This field is required.

Aetna (In-Network)

Anthem (In-Network)

Availity (In-Network)

Beacon - Carelon (In-Network)

Blue Cross(In-Network)

Blue Shield (In-Network)

Blue Shield+Blue Cross (In-Network)

Carelon (In-Network)

Cigna - Evernorth (In-Network)

Evernorth (In-Network)

Healthnet (In-Network)

Humana (In-Network)

Kaiser (Available in Modesto Area Only)

MHN (In-Network)

Magellan (In-Network)

Medi-Cal (Only in Santa Clara & Stanislaus County)

Medicare NOT ACCEPTING

Optum (In-Network)

Tri-Care (In-Network)

Tri-West (In-Network)

United (In-Network)

Uninsured

Other

Check insurance coverage for these services?* This field is required.

Yes

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Yes

Thank you for your interest. Click here to clear your data.

Kaiser coverage is limited to Modesto/Turlock/Merced area. Do you within with area?* This field is required.

Yes

Sorry, We Do Not Accept Insurance for the services you are requesting.

We only accept insurance for treating depression with TMS. These are some of the insurance company's requirements to authorize TMS Treatment:

1) Major Depression

2) Have tried antidepressants

3) Some talk therapy

4) 18 or older

5) Treatment is for 36 TMS sessions

6) Limited to one treatment a day, maximum 5 a week for 7 weeks

(We do not accept Medicare)

All of our services are available on a self-pay basis. Our Services do qualify for HSA accounts.

Would you like to proceed on a self-pay basis? We will provide a detailed, itemized receipt. HSA & Credit Cards accepted* This field is required.

Yes

Would you like to be added to our mailing list?* This field is required.

Yes

Thank you for your interest. Click here to clear your data.

Good news! Your plan may cover depression treatment using TMS. Would you like to schedule your free consultation appointment now?* This field is required.

Yes

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Yes

Thank you for your interest. Click here to clear your data.

Please Review Our Fees Before Making an Appointment.

Self-Pay Fees (For those without insurance coverage) starts at $3,000 and up. For detailed pricing, please visit our website. https://www.brainwellnesscenter.com/insurance___costs/

We encourage all potential patients to review our fee structure before making an appointment to avoid any disappointment or misunderstanding.

After reviewing the cost of our services, would you still like to proceed?* This field is required.

Yes

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Yes

Thank you for your interest. Click here to clear your data.

How did you hear about us?* This field is required.

Doctor Referral

Google/Search Engine

Family/Friend

Facebook or other Social Media

Other

Thank you for your interest. Check back soon, as conditions do change quickly. Please press SUBMIT and you will be added to our mailing list.

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