TMS Intake Survey Logo

  • Medication Management Intake Survey

  • We are glad you are interested to select Acacia as your Psychiatry Provider. We'd love to get to know you a little better. 

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  • Over the last 2 weeks, how often have you been bothered by any of the following problems?

  • Other Providers

    Great job so far! This next section is lets us know a bit more about your past providers. As with all sections, the more information you share, the better and faster we can answer your questions, but it is not required.
  • Clear

  • Next, we'll ask you more about your past antidepressants (up to 6). We understand it can be hard to remember details, and all of this will be confirmed with a physician before any decisions are made. Approximate answers (especially on dates) are just fine. Start from the medication you started most recently, and work your way back in time.

  • Medication #1

    The following questions will be about the medication you started MOST RECENTLY.

  • Medication #2

    The following questions will be about the medication you started second-most recently.

  • Medication #3

    The following questions will be about the medication you started second-most recently.

  • Medication #4

    The following questions will be about the medication you started second-most recently.

  • Medication #5

    The following questions will be about the medication you started second-most recently.

  • Medication #6

    The following questions will be about the medication you started second-most recently.

  • Financial Information

  • While we would like to focus on the clinical aspects of care, we realize that finances can be a barrier. In order to minimize delays in care, we give you the option of giving insurance information.

  • Please answer the following questions for the household financially responsible for you (e.g. if a spouse financially supports you, please answer for your hosehold; if you parents support you, please answer for them). Approximations on the following numbers are acceptable. We may request documentation (e.g. IRS 1040 from a previous year) to verify these numbers.

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