Date of Referral*

Date of Visit

Patient Name*

First NameLast Name

Phone Number (Mobile) to Call or Text you back*

Please enter a valid phone number.

The Clinician Your Seeing in the Practice:*

Faisal Rafiq MD.Yasmine Saim, MMSc, PA-CJoan Mahoney NP.Not Seeing A Clinician in Psychvisit

Diagnosis to be Treated:*

DepressionObsessive Compulsive Disorder

The Number of Antidepressants you have Trialed by history:*

2345 or more

Name of Therapist and How long was the treatment:*

You Must meet the Below Criteria Before Proceeding:*

You have to Obtain pharmacy records or Proof of Previous Medication Treatment-either to upload to the website or Bring inYou Must have had 6 or more months in therapyYou Must have failed Multiple Anitdepressants

What Commercial Insurance Plan do you have?*

Do You Want Any Particular Machine?*

BrainswayCloud TMSEither Machine is fine

Transcranial Magnetic Stimulation (TMS) Patient Education Statement:
Transcranial Magnetic Stimulation (TMS) is a non-invasive neuromodulation therapy approved for the treatment of Major Depressive Disorder (MDD) in adults who have not responded adequately to antidepressant medications. This treatment uses magnetic fields to stimulate neural pathways associated with mood regulation.

What to Expect:
Initial Assessment: Before undergoing TMS, you will be evaluated to confirm the diagnosis and to assess suitability for the treatment. This typically involves a thorough medical history and possibly neuroimaging tests.
Consent: Prior to starting treatment, you must read and sign an informed consent form, which outlines the potential risks and benefits of TMS.
Treatment Sessions: A TMS session generally lasts about 30-60 minutes. During the session, you will be awake and seated comfortably, while a magnetic coil is placed against your scalp.
No Anesthesia: TMS does not require anesthesia and is typically well-tolerated, with minimal side effects such as scalp discomfort or headache.
Frequency of Sessions: The treatment usually consists of multiple sessions per week for a duration determined by your healthcare provider.
Potential Side Effects: Common side effects include scalp discomfort and headaches. Less commonly, TMS may cause lightheadedness or tingling in facial muscles. Serious but rare side effects include seizures.
Monitoring: Your mental and physical health will be monitored throughout the treatment period to assess efficacy and adjust treatment parameters as necessary.
Post-Treatment Care: Follow-up appointments will be scheduled to evaluate the outcomes of the treatment and to consider future therapeutic strategies.
Commitment: Successful treatment often requires a strong commitment to attending all scheduled sessions and follow-up appointments.
By acknowledging this patient education statement, you confirm your understanding of what TMS involves and agree to adhere to the recommended treatment plan.

Upload Pharmacy Records

Reason for Picking a Specific Machine or Reason for TMS Therapy:*

TMS Referral Request and Education