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University Place TMS Clinic
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INTAKE FORM
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Intake form
Help us serve you better
Full Name
*
Email address
*
What is your date of birth?
What is your phone number?
What is your primary reason for seeking treatment?
Please select at least one option.
Medication Resistant Major Depressive Disorder (MRMDD)
Anxious Depression
Obsessive Compulsive Disorder (OCD)
Late Life Depression
Are you currently taking any medications?
Please select at least one option.
Yes
No
Have you previously received any mental health treatment?(Specify)
If yes, please list the medications you are currently taking.
Do you have any known allergies?
Please select at least one option.
Yes
No
If yes, please specify the allergies.
How did you hear about University Place TMS Clinic?
Select
Referral
Online search
Social media
Which service or services are you interested in?
Please select at least one option.
Deep TMS Treatment for Major Depressive Disorder (MDD)
Deep TMS Treatment for Anxious depression treatment
Deep TMS Treatment for Obsessive Compulsive Disorder (OCD)
Deep TMS Therapy for Late Life Depression
Additional questions or comments
Select a date and time for in-person initial consult
*
Select a date and time
September
2018
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