Intake Form - TMS Restoration Psychiatry

Please attempt to complete every question to the best of your knowledge.

First Name

Last Name

Home Address

City

Zip

Home Phone

Cell Phone

Work Phone

Email Address

Primary Care Physician:

PCP Phone

PCP Fax

City

State

Zip

Please Complete All Items for Proper Review. Please DO NOT Leave Any Items Blank:

Current Age

Primary Insurance Carrier Name

Secondary Insurance Carrier Name

Current Psychiatrist Name and Address

Previous Psychiatrist Name and Address

Reason for Leaving the Above Psychiatrist

Current Therapist Name and Address

Are you currently suicidal?

Yes

No

Are you currently Homicidal?

Yes

No

What is your current diagnosis?

Which controlled substance are you currently on? (Medicinal cannabis, Percocet, Oxycodone, Hydrocodone, Morphine, Xanax, Klonopin, Adderall, Valium, Ritalin, Ativan, etc.)

Which controlled substance do you expect to be prescribed?

How much alcohol do you drink?

Which recreational drug (s) do you currently use?

Do you have a legal case pending? If yes, briefly describe this. If no, please leave blank.

Are you currently on disability?

Yes

No

Do you need disability paperwork completed?

Yes

No

Emergency Contact(s)

Name

Relationship to Patient

Cell Phone

Home Phone

Work Phone

Address

How has depression and anxiety affected you in terms of:

Relationships

Work

Socialization

Hobbies

Education

If you have any further questions/concerns or information you would like us to consider during your intake’s review, please include it below

TMS Therapy Intake Questionnaire

Locations