TMS Intake Information

First Name *

Middle Initial

Last Name *

TRICARE insurance? *

Yes

No

SSN *

Policy number *

Date of birth * +

Age *

Gender *

Male

Female

Street Address *

Address Line 2

City *

State *

Zip Code *

What is the preferred number to reach you at? *

Phone Number *

Would you like to add another contact number? *

Yes

No

Phone Number

Best time to call *

7:30 - 9:00

9:00 - 12:00

12:00 - 3:00

3:00 - 5:00

Email Address *

We provide courtesy appointment reminders. If you would like to receive a reminder, please let us know which method you prefer or you may opt out. Standard messaging rates may apply for texts. Confirmation reminders are a courtesy only. It is still your responsibility to make all your appointment. *

Text

Call

I opt out

Cell Carrier? *

Emergency contact information

	Name	Phone number	Relationship
1	Name	Phone number	Relationship
2	Name	Phone number	Relationship

Responsible Financial Party

We require a credit card to be placed on file. Cards are securely filed and will be used only for payment of co-pays, co-insurance, payments for service and no-show fees. Credit card information must be entered even if you are not the responsible party.

TRICARE Prime and Active Duty Service Member will not be charged a co-pay but must still put card information for any no-show fees.

Is financial responsibility someone other than the patient? *

Yes

No

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Security Code *

By checking the box below, you agree that we may charge the card provided for the amount owed the day after it is reflected on the account. *

I agree

Screening Tools

TMS Consent Form

You must read the consent form before proceeding. By checking this box, you acknowledge that you have read the TMS Consent for Treatment. *

Agree

TMS Screening Questionnaire *

	No	Yes
Have you ever had an adverse reaction to TMS?	No	Yes
Have you ever had a seizure?	No	Yes
Have you ever had an EEG	No	Yes
Have you ever had a stroke?	No	Yes
Have you ever had a head injury (include neurosurgery)?	No	Yes
Do you have an metal in your head?	No	Yes
Do you have any implanted devices such as cardiac pacemakers, medical pumps, or intracardiac lines?	No	Yes
Do you suffer from severe headaches?	No	Yes
Have you ever had any other brain-related condition?	No	Yes
Have you ever had any illness that caused brain injury?	No	Yes
Are you taking any medications?	No	Yes
If you are a woman of childbearing age, are you sexually active, and if so, are you using a reliable method of birth control?	No	Yes
Does anyone in your family have epilepsy?	No	Yes
Do you need further explanation of TMS and its associated risk?	No	Yes

PHQ-9 *

	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things	Not at all	Several days	More than half the days	Nearly every day
Feeling down, depressed, or hopeless	Not at all	Several days	More than half the days	Nearly every day
Trouble falling or staying asleep, or sleeping too much	Not at all	Several days	More than half the days	Nearly every day
Feeling tired or having little energy	Not at all	Several days	More than half the days	Nearly every day
Poor appetite or overeating	Not at all	Several days	More than half the days	Nearly every day
Feeling bad about yourself, or that you are a failure or have let yourself or your family down	Not at all	Several days	More than half the days	Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching TV	Not at all	Several days	More than half the days	Nearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual	Not at all	Several days	More than half the days	Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way	Not at all	Several days	More than half the days	Nearly every day

Medication History

*

	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)
Medication 1	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)
Medication 2	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)
Medication 3	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)
Medication 4	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)
Medication 5	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)
Medication 6	Medication	Dosage	Duration	Response (please note if discontinued due to side effects)

Any other pertinent treatment history (hospitalizations or treatment) *

Yes

No

Prior OUTPATIENT psychotherapy. *

Yes

No

How many times?

Dates if known.

+-

Diagnosis *

Therapist information

	Name	City, State	Phone number
1	Name	City, State	Phone number
2	Name	City, State	Phone number
3	Name	City, State	Phone number
4	Name	City, State	Phone number
5	Name	City, State	Phone number

Prior INPATIENT treatment for psychiatric, emotional, or substance use disorder? *

Yes

No

How many times?

Dates if known.

+-

Diagnosis *

Inpatient facility information

	Name	City, State	Phone number
1	Name	City, State	Phone number
2	Name	City, State	Phone number
3	Name	City, State	Phone number
4	Name	City, State	Phone number
5	Name	City, State	Phone number

Notices

Family Care Center Notices

By checking this box, you acknowledge that you have read the notices above. *

Agree

Acknowledgement and Signature

By signing this form, you agree that you are willing to be seen by a provider at the Family Care Center and will become a client of this clinic upon submission of this form. Clients are responsible for all payments at time of service. Clients who do not show up for this initial appointment or any subsequent follow-up appointments are subject to a $50 no-show fee which must be paid prior to any further appointments being made. Two or more no-shows for an initial appointment can result in you not being accepted as a client. *

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