Please contact me

This form is for the staff of Psychiatry Northwest to record a new patient or internal referral inquiry. By completing this form you are starting the process of managing a patient or colleague with suburb customer service.

Please complete as much of the information as possible.
This individual is best described as

A phone call from an individual seeking care for themselves.A phone call from an individual seeking care for a loved one or friend.An external healthcare referral source.One of our providers.A current patient seeking more information about TMS therapy.
Patient Name
Email
example@example.com
Phone Number

Area CodePhone Number
Who is the referring office or provider. Please provide as much information as needed.
PRovider name, practice, address.
They are interested in. Check all that applies.

Medication ManagementADD / ADHD OptionsQB TestTMS TherapyPsychotherapy / Talk TherapyOther:
Which best describes their health care coverage?

They do not have health care insurance.MEDICARE.Commercial health insurance (examples Aetna, Blue Cross / Blue Shield, Cigna, United Health Care etc.)TricareMedicaid
Which of the following, best describes their diagnosis?

Clinical Depression, Major Depressive Disorder, MDDBipolar DisorderGeneralized Anxiety DisorderPTSD - Post Traumatic Stress DisorderOCD - Obsessive Compulsive DisorderSchizophrenia or Psychosis of some formI do not know / Other

How severe are their symptoms?

	1	2	3	4	5	6	7	8	9	10

1 is No Symptoms, 10 is Very Severe Symptoms

Within the last TWO - Years, how many medications for their mental health concern have you taken?

I have not tried any medications1 or 23 or 4More than 4
Please check ALL that applies then click the submit button.

They have no interest in TMS therapyThey do not understand TMS therapyThey have some knowledge of TMS therapyThey have a strong knowledge of TMS therapy
Please feel free to provide more information.
What are the next steps to help this individual?
Please click the Submit button below so we may

get back to you in a timely manner.
Should be Empty: