History Questionnaire

1Your Info

2Therapy History

3Anti-depressants

4Anti-psychotics

5Medical History

Therapy History
Have you tried TMS before?*
- Yes
- No
Previous Doctor*
Hz*
Date Began*
MM slash DD slash YYYY
Date Ended*
MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.
Was it Successful*
Are you currently in or have you ever tried talk therapy?*
- Yes
- No
Previous Therapist*
Date Began*
MM slash DD slash YYYY
Date Ended*
MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.
Was it Effective*

This form is a preauthorization form forTMS, Spravato (Ketamine), or combination therapy. Please fill this out to expedite your treatment process.

847-236-9310