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TMS Screening Form

  1. Please answer the questions honestly and to the best of your ability.

  2. There are no "right" or "wrong" answers.

  3. These questions are a baseline for further medical investigation to determine if TMS is the correct next step for you.

Are you 18 years old or older?
Have you been diagnosed with a seizure disorder?
Do you have any metal or medical devices implanted in your head or chest?
Are you pursuing TMS for Severe Depression?
Are you pursuing TMS for treating OCD?
Have you received TMS before?
Have you taken medications for depression and/or OCD (including current and past)? If yes, how many?
Have you ever participated in talk therapy?
Have you ever worked with a psychiatrist or psychiatric prescriber?
Does your current psychiatrist or psychiatric prescriber know you are pursuing TMS?

Patient Information:

Primary Insurance Information:

Are you the subscriber or policy holder to your current plan?
Relation to Subscriber:
Upload File
Upload File
Do you have a secondary or supplemet insurance plan?
Are you the policy holder of your secondary insurance policy?
Relation to subscriber of secondary insurance plan:
Upload File
Upload File

After submitting this screening form, you will be directed to another link and asked to complete a short survey that captures a current status of your mental health symptoms.   

By Completing this Survey,
Our review process will be expedited!

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