TMS Intake Information

TRICARE insurance? *
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Gender *
Would you like to add another contact number? *
Best time to call *
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. *
Emergency contact information
 NamePhone numberRelationship
1
2

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? *
Visa
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. *

Screening Tools

You must read the consent form before proceeding. By checking this box, you acknowledge that you have read the TMS Consent for Treatment. *
TMS Screening Questionnaire *
 NoYes
Have you ever had an adverse reaction to TMS?
Have you ever had a seizure?
Have you ever had an EEG
Have you ever had a stroke?
Have you ever had a head injury (include neurosurgery)?
Do you have an metal in your head?
Do you have any implanted devices such as cardiac pacemakers, medical pumps, or intracardiac lines?
Do you suffer from severe headaches?
Have you ever had any other brain-related condition?
Have you ever had any illness that caused brain injury?
Are you taking any medications?
If you are a woman of childbearing age, are you sexually active, and if so, are you using a reliable method of birth control?
Does anyone in your family have epilepsy?
Do you need further explanation of TMS and its associated risk?
PHQ-9 *
 Not at allSeveral daysMore than half the daysNearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself, or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching TV
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
Thoughts that you would be better off dead or of hurting yourself in some way

Medication History

 *
 MedicationDosageDurationResponse (please note if discontinued due to side effects)
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Any other pertinent treatment history (hospitalizations or treatment) *
Prior OUTPATIENT psychotherapy. *
Dates if known.
Therapist information
 NameCity, StatePhone number
1
2
3
4
5
Prior INPATIENT treatment for psychiatric, emotional, or substance use disorder? *
Dates if known.
Inpatient facility information
 NameCity, StatePhone number
1
2
3
4
5

Notices

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

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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