TMS Self-Screening Form

Screen Form
Patient Information
Primary Insurance Information

1.Are you 18 years old or older?*YesNo

2.Have you been diagnosed with a seizure disorder?*YesNo

3.Do you have any metal or medical devices implanted in your head or chest?*YesNo

4.Are you pursuing TMS for Severe Depression?*YesNo

5.Are you pursuing TMS for treating OCD?*YesNo

6.Have you received TMS before?*YesNo

7.Have you taken medications for depression and/or OCD (including current and past)? If yes, how many?*Yes, 4 or more different kinds.Yes, 2 to 3 different kinds.Yes, only 1No, never

8.Have you ever participated in talk therapy?*Yes, currentlyYes, in the pastNo, never

9.Have you ever worked with a psychiatrist or psychiatric prescriber?*Yes, currentlyYes, in the pastNo, never

1.Does your current psychiatrist or psychiatric prescriber know you are pursuing TMS?*Yes, they referred me to you.Yes, we discussed in the past.No, they aren't aware, but I understand that you may communicate with them to determine my eligibility for TMS.

Screen Form
Patient Information
Primary Insurance Information

1.Patient First Name*

2.Patient Last Name*

3.Date of Birth*

4.Phone*

5.Email*

6.Patient Address*

Screen Form
Patient Information
Primary Insurance Information

1.Primary Insurance Carrier Name*

2.Primary Insurance Member ID #/ Subscriber ID #*

3.Primary Insurance Group Number*

4.Are you the subscriber or policy holder to your current plan?*YesNo

1.Relation to Subscriber*Spouse ofChild of

2.Subscriber Name (First, Last)*

3.Subscriber Phone*

4.Subscriber DOB*

5.Front of Primary Insurance Card*

Upload supported file (Max 5MB)

6.Back of Primary Insurance Card*

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7.Do you have a secondary or supplemet insurance plan?*YesNo

1.Name of Secondary / Supplement Insurance Policy*

2.Secondary Insurance: Member ID # / Subscriber ID #*

3.Secondary Insurance: Group Number*

4.Are you the policy holder of your secondary insurance policy?*YesNo

5.Relation to subscriber of secondary insurance plan*Spouse ofChild of

6.Secondary / Supplement Insurance: Subscriber Name (First, Last)*

7.Secondary / Supplement Insurance: Subscriber Phone*

8.Secondary / Supplement Insurance: Subscriber DOB*

9.Front of Secondary Insurance Card*

Upload supported file (Max 5MB)

10.Back of Secondary Insurance Card*

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I certify that the above information is correct to the best of my knowledge and that I have not purposefully misrepresented my health history. I understand it is my responsibility to keep my information accurate and up to date and will notify the office of any changes in health, insurance or contact information. I will not hold my prescriber or any staff member of Collaborative Solutions in Psychiatry, SC (CSIP) responsible for errors or omissions that I may have made in completing this form. I hereby authorize payment directly to my health care provider for all insurance benefits otherwise payable to me for services rendered. I authorize the providers of the office of CSIP to release the information required to secure the payment of benefits. I authorize this use of this signature on all insurance submissions. I understand that the information provided above will be used in screening to determine my eligibility for TMS services. By completing this form, I acknowledge that the TMS Center may find that I do not qualify for TMS.

Your Signature*

NOTE

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.

TMS Self-Screening Form

TMS Screening Form

NOTE

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