Who are you completing this form for? *

Relationship To Patient *

1. How old is the patient? *

0 - 17 years old

18 years old + above

2. Will the patient need any language interpretation services? *

Yes

No

Primary Language *

3. Is the patient currently involved in any worker's compensation, or legal issues related to treatment? *

Yes

No

Please describe worker's compensation or legal issues. *

4. In the past 6 months, has the patient experienced auditory, visual hallucinations or paranoid thoughts? *

Yes

No

Please describe recent auditory or visual hallucinations or paranoid thoughts. *

5. Is the patient currently struggling with addiction or seeking substance abuse treatment to a substance other than marijuana or nicotine? *

Yes

No

Please explain addiction or substance use treatment the patient is seeking. *

6. Is the patient looking to be prescribed one of the following medications: methadone, suboxone, Subutex, buprenorphine/naloxone or belbuca? *

Yes

No

Please list medications patient is currently prescribed. *

7. Has the patient had a suicide attempt in the past 3 months? *

Yes

No

Treatment of Interest *

Primary Reason For Visit *

How did you hear about us? *

Please enter the name of the provider who referred you. *

Other Referral *

Patient Date of Birth *

Patient Street Address *

City *

State *

Country

ZIP code *

How will you be paying for your visits? *

Psychiatry Services

Initial Psychiatric Evaluation — $700
30-Minute Follow-Up Appointment — $250

TMS Treatment Pricing

TMS Session — $250 per treatment
TMS Package Options
- Accelerated TMS (5-Day Program): 50 treatments × $250 = $12,500
- Standard Course (Typical 36 Sessions): 36 treatments × $250 = $9,000
- One-Day Intensive (20 Sessions): 20 treatments × $250 = $5,000

Primary Insurance *

Name of Other Insurance *

Are you the primary policy holder? *

Yes

No

First & Last Name of Policy Holder *

Do you have a Secondary Insurance? *

Yes

No

Secondary Insurance *

Upload a photo of the FRONT of your Insurance Card(s) *

Upload a photo of the BACK of your Insurance Card(s) *

Driver’s License or Other Government ID *

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