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Cuestionario Canidate TMS

 

TMS - Screener - English

In order to facilitate your assessment for Transcranial Magnetic Stimulation (TMS) services, we ask you to please complete this TMS Assessment Questionnaire. Once you submit it, we will contact you within 24 hours to discuss your treatment options and schedule an appointment with Alfredo Arellano PMHCNS-BC for an initial evaluation, if you so desire.

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Input your DOB, please note TMS services are only offered to those 18 and older
Please input your email address
Please make sure this is correct, we will contact you using this number
I am interest in Transcranial Magnetic Stimulation for; *
Have you been diagnosed with Major Depression? *
Depressive symptoms I currently experience include (check all that apply):
Anxiety Symptoms I currently experience include (check all that apply):
I am currently in counseling with a therapist, psychologist or counselor.
In my lifetime, I have been on 2 or more antidepressants, mood stabilizers or antipsychotics *
I have not had any brain surgery and have no metals in my head (like aneurysm clips or coils, brain stimulators, cochlear implants etc..).
I am interested in Transcranial Magnetic Stimulation Treatments because: *
Transcranial Magnetic Stimulation (TMS) is covered by most insurances. My insurance carrier is: