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

Martial Status
Employment Status (Select all that apply)

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

Are you currently suicidal?
Are you currently Homicidal?
Are you currently on disability?
Do you need disability paperwork completed?

Emergency Contact(s)

TMS Therapy Intake Questionnaire

Have you heard about Transcranial Magnetic Stimulation?
Are you interested in this non-drug treatment for depression/anxiety?
Are you in therapy right now?
Do you have any metallic objects implanted in or around your head?

Select ALL psychiatric medications you have tried in the past

Atypical antidepressants:
Selective serotonin Reuptake inhibitors (SSRIs)
Serotonin-Norepinephrine Reuptake inhibitors (SNRIs)
Tricyclic antidepressants
Monoamine oxidase inhibitors (MAOIs)
Mood Stabilizer

How has depression and anxiety affected you in terms of: