Holistic Psychiatry & Wellness Center
Home
Services
Psychiatric Evaluations & Mental Health
Medication Management
Psychedelic-Assisted Psychotherapy
Transcranial Magnetic Stimulation (TMS)
About
Contact
Book Appointment
Menu
Book appointment
TMS Patient Referral Form
TMS Patient Referral Form
1. Patient Information
Name
(Required)
First
Last
Date of Birth
(Required)
Month
Day
Year
Address
(Required)
Phone Number
(Required)
Email
(Required)
Town/City
(Required)
State
(Required)
ZIP Code
(Required)
May we leave a voicemail at this number to schedule an appointment?
Yes
No
Primary Insurance
(Required)
Policy #
(Required)
Group #
(Required)
Policy Holder Name
(Required)
Card / Bin #
(Required)
Caregiver Name and Phone
(Required)
Please fax or attach a copy of the insurance card(s). Nearly all plans require prior authorization with documented medication trials.
2. Clinical History and Safety Screening
Diagnosis
Antidepressant Trial History (Agent, Dose, Duration, Outcome)
Current Medications
Non-removable metal or an implanted electronic device in or near the head?
(Required)
Yes
No
History of seizure, epilepsy, or a condition lowering the seizure threshold?
(Required)
Yes
No
Prior head injury, stroke, neurosurgery, or intracranial mass?
(Required)
Yes
No
Additional medical reports and supporting documents are included with this form.
(Required)
Yes
No
Details/Other Relevant History
If yes to any of the above, please describe it here.
3. Referring Healthcare Provider
Name
(Required)
First
Phone Number
(Required)
Fax Number
Practice
(Required)
Email
(Required)
Please send me updates about my patient by:
(Required)
Phone
Email
Fax
Referring Provider Signature
(Required)
Max. file size: 1 GB.
Date
(Required)
MM slash DD slash YYYY
CAPTCHA
Sign in
Create an Account
Username or email
*
Password
*
Login
Lost your password?
Main menu
Home
Services
Psychiatric Evaluations & Mental Health
Medication Management
Psychedelic-Assisted Psychotherapy
Transcranial Magnetic Stimulation (TMS)
About
Contact
Book Appointment
Home
About us
Blogs
Contact Us
Medication Management Referral Form
Privacy Policy
Psychiatric Evaluations & Mental Health
Spravato Patient Referral Form
TMS Patient Referral Form
Top
