NeuroHeal TMS | TMS Therapy In Norwell MA

First Name

Last Name

Phone:

Email

State

Zip

Primary Insurance

Insurance ID #

Insurance Customer Service Number (back of card)

Behavioral or Mental Health Number (on back of card)

Primary Subscriber? (self, spouse, parent, etc)

Have you had TMS therapy before?

Yes

No

Have you had ECT before?

Yes

No

If 'yes' to previous TMS, tell us more? (when, where, & was it helpful))

If 'yes' to previous ECT, tell us more (when, where, and was it helpful)?

Please tell us which conditions you've been diagnosed with?

Do any of the following apply to you? (please check all that apply)

Seizure disorder or epilepsy

Eating Disorder

Metal in or around the head

Pacemaker or defibrillator

Do you have a Psychiatrist of prescribes your medications?

Yes

No

Do you have or have you had a therapist or counselor?

Yes

No

Name of Current or Previous Psychiatrist?

Phone number of psychiatrist named above?

Phone number of therapist or counselor mentioned above?

Have you tried any of the below types of psychotherapy?

If you've tried therapy/counseling, how long did you attend and how frequently were your visit (i.e. weekly for 6-month)?

When did you attend therapy, counseling, or group therapy (i.e. Jan 2020 - Sept 2020 - please be as specific as possible)?

Please provide additional information about your history of psychotherapy or counseling, etc. not provided above)

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Please list all previous (not current) antidepressant medication trials (include dose take, and approximate start and stop dates)?

Doctors often prescribe other psychiatric medications to 'augment' an antidepressant, have you ever tried any psychiatric medications not previously listed (i.e. Abilify, Lamictal, Rexulti, etc.)?

Please tell us what symptoms you are currently experiencing (check all that apply)?

Please list any other information you feel if relevant for us to know.

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TMS Registration Form

Contact Us

293 Washington St., Rear

Norwell, MA 02061

Email: Info@NeuroHEALtms.com

Contact: 617-588-0102