INTAKE FORM - TMS of Johnson City TN

TMS of Johnson City/Crestpoint Psychiatric: Please complete this form and submit to enable us to obtain prior authorization from your insurance carrier for your TMS/SPRAVATO treatment.

Full Name

Date of Birth*

Cell Phone Number*

Email Address*

Home Address (Street, City)*

Home Address (Zip code, State)*

Health Insurance Carrier*

Insurance ID Number*

Attach a copy of the Front of your Insurance Card*

Who is the primary on the insurance?

Self
Spouse
Parent

Full Name and Date of Birth of the primary Insured. If you are the primary, type "self".*

Please answer the questions below.

Are you interested in ESKETAMINE treatment for depression?

YES
NO

Are you interested in Transcranial Magnetic Stimulation (TMS) for depression or anxiety?

YES
NO

Have you ever taken Amitriptyline, Nortriptyline, clomipramine, Doxepin? If “YES”, please list.*

Have you ever taken Lexapro, Prozac, Celexa, Lexapro, Zoloft, Paxil? If “YES”, please list.*

Have you ever taken Pristiq, Effexor, Cymbalta, Wellbutrin, Trintellix? If “YES”, please list.*

Have you ever taken Latuda, Rexulti, Remeron, Viibyrd, Elavil, Abilify? If “YES”, please list.*

Did you stop taking psychiatric medications because of side effects?

Yes
No

List the side effects you had from taking psychiatric medications.*

List your current Psychiatric Medications.*

Have you ever been in counselling or therapy?

Yes
No

Are you currently in counselling or therapy?

Yes
No

If are currently in counselling, do you attend sessions weekly, biweekly, or once a month? “N/A” if None.*

Name of Therapist and phone number. If none, type "N/A"*

Do you have any metal implants (brain clips, brain stent, shrapnel, bullet fragments) in the brain/head or neck area?

Yes
No

Do you have a history of epilepsy or seizures?

Yes
No

Do you have any implanted neurostimulator (e.g., Deep brain stimulator, epidural or subdural nerve stimulator)?

Yes
No

Do you have any cochlear implants (inside your ears)?

Yes
No

Do you have any hearing problems or ringing in my ears?

Yes
No

Do you have a cardiac pacemaker or any intracardiac or intravascular lines or metal in my body?

Yes
No

Have you ever had a brain bleed or any blood vessel/bleeding problems?

YES
NO

Have you been diagnosed with Bipolar disorder?

Yes
No

Have you been diagnosed with Schizophrenia ?

Yes
No

TMS treatment requires you to come into the office daily (5 days a week) for 6 weeks. Can you commit to this?

Yes
No
N/A

Intranasal ketamine treatment requires that you MUST have a designated driver who will pick up you from the office after your treatment as you are NOT allowed to drive for 24 hours after each treatment session. Do you have someone that you can designate as YOUR DRIVER?

YES
NO
N/A