Internal Only TMS Referral Form
Aura ID
Staff
Status
New
Source
*
Please Select
TCP
OP Counseling
OP PNP
Public Safety
Crisis
First Name
*
Last Name
*
Patient DOB
*
-
Month
-
Day
Year
Date
Patient Phone
*
Format: (000) 000-0000.
Patient Primary Insurance Carrier
*
Aura URL
*
(Copy and Paste the URL from the Patient Chart in Aura)
How long has client been in counseling services?
Referring Provider Name
*
Does client have a major depressive diagnosis?
*
Yes
No
Has cilent tried talk therapy before?
*
Yes
No
Was talk therapy enough to get rid of their depression?
*
Yes
No
Has client tried any of the medications listed below to help with your depression?
*
Yes
No
(SSRIs) include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), fluvoxamine CR (Luvox CR), paroxetine (Paxil), paroxetine CR (Paxil CR), sertraline (Zoloft). (SNRI's) desvenlafaxine (Pristiq), duloxetine (Cymbalta), venlafaxine (Effexor), venlafaxine XR (Effexor XR), milnacipran (Savella), and levomilnacipran (Fetzima), (TCA's) amitriptyline (Elavil), desipramine (Norpramin), doxepine (Sinequan), Imipramine (Tofranil), nortriptyline (Pamelor), amoxapine, clomipramine (Anafranil), maprotiline (Ludiomil), trimipramine (Surmontil), and protriptyline (Vivactil).
Did client do the maximum dose for at least 6 weeks or did you have a side effect that prevented you from taking it for 6 weeks?
*
Yes
No
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling down, depressed, or hopeless
*
Not at all
More than half days
Some days
Nearly every day
Trouble falling or staying asleep, or sleeping too much
*
Not at all
More than half days
Some days
Nearly every day
Feeling tired or having little energy
*
Not at all
More than half days
Some days
Nearly every day
Poor appetite or overeating
*
Not at all
More than half days
Some days
Nearly every day
Feeling bad about yourself – or that you are a failure or have let yourself or your family down
*
Not at all
More than half days
Some days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
More than half days
Some days
Nearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual.
*
Not at all
More than half days
Some days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
*
Not at all
More than half days
Some days
Nearly every day
PHQ9 Score
Submit
Should be Empty: