Full Name
Email Address
Phone Number
1. Since TMS therapy is conducted in-house, are you able to attend treatment sessions at our clinic?
Yes
No
2. What symptoms are you hoping to treat? (Select all that apply)
Depression
Anxiety
OCD
PTSD
Other
3. Is this for you or someone you care about?
Self
Loved one
4. How many prescription medications have you tried for your mental health?
0
1
2
3 or more
5. Do you currently have health insurance? If yes, which insurance provider do you have?
Yes
No
Insurance Provider
Name
This field is for validation purposes and should be left unchanged.
×
Scroll to Top