TMS Referral Form

Internal Only TMS Referral Form
Aura ID
Staff
Status

New
Source*
First Name*
Last Name*
Patient DOB*

MonthDayYear
Date
Patient Phone*
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?*

YesNo
Has cilent tried talk therapy before?*

YesNo
Was talk therapy enough to get rid of their depression?*

YesNo
Has client tried any of the medications listed below to help with your depression?*

YesNo
(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?*

YesNo
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling down, depressed, or hopeless*

Not at allMore than half daysSome daysNearly every day
Trouble falling or staying asleep, or sleeping too much*

Not at allMore than half daysSome daysNearly every day
Feeling tired or having little energy*

Not at allMore than half daysSome daysNearly every day
Poor appetite or overeating*

Not at allMore than half daysSome daysNearly every day
Feeling bad about yourself – or that you are a failure or have let yourself or your family down*

Not at allMore than half daysSome daysNearly every day
Trouble concentrating on things, such as reading the newspaper or watching television*

Not at allMore than half daysSome daysNearly 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 allMore than half daysSome daysNearly every day
Thoughts that you would be better off dead or of hurting yourself in some way*

Not at allMore than half daysSome daysNearly every day
PHQ9 Score
Should be Empty:

Internal Only TMS Referral Form

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