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 Code Phone 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 Management ADD / ADHD Options QB Test TMS Therapy Psychotherapy / Talk Therapy Other:

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.) Tricare Medicaid

Which of the following, best describes their diagnosis?

Clinical Depression, Major Depressive Disorder, MDD Bipolar Disorder Generalized Anxiety Disorder PTSD - Post Traumatic Stress Disorder OCD - Obsessive Compulsive Disorder Schizophrenia or Psychosis of some form I 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 medications 1 or 2 3 or 4 More than 4

Please check ALL that applies then click the submit button.

They have no interest in TMS therapy They do not understand TMS therapy They have some knowledge of TMS therapy They 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.