Personalized Mental Healthcare & Treatments

Pre-Assessment Questions

Patient Information

Name(Required)

First Last

Email(Required)

Phone(Required)

For what reason are you seeking treatment?

What is your date of birth?(Required)

On a scale of 1 through 10, how stressful is your living environment?

On a scale of 1 through 10, how supportive is your living environment?

Which locations are you interested in?(Required)

Santa Monica/West LA

Downtown Los Angeles

Las Vegas

Virtual (CA only)

What is the name of the individual filling out this form?

What is your address?

Address Line 2 City State ZIP Code

Marital Status

Employment Status

Full Time

Part Time

Retired

Unemployed

Education Level

Which of the following treatments will you be interested in being evaluated for?(Required)

If you are requesting services for treatment resistant depression, when did the treatment resistant depression begin?

Do you have any current medical diagnoses?

Yes

What are your current medical diagnoses?

Diagnosis

Date Diagnosed

Have you received mental health treatment before?

Yes

Please list the name of the clinic or provider that you've received treatment at in the past.

Provider

Provider Phone

Treated For

Date Treated

Please include provider phone, dates you were treated, and what you were treated for

Are you currently under the care of a psychiatrist?

Yes

Psychiatrist name

Psychiatrist phone

Please include dates you were treated, and what you were treated for by the above psychiatrist

Treated For

Date Treated

Are you currently in or have you ever tried psychotherapy or counseling?(Required)

Yes

What is the name of your most recent therapist or counselor?

Approximately when did you start seeing the above therapist or counselor?

Approximately when did you stop seeing the above therapist or counselor?

Do you plan on using your insurance?

Yes

What is your insurance?

Insurance

Member ID

Medication

Collecting information about the medications you have taken, including the dosage, duration, and timing of use, is crucial for the approval process. Insurance providers typically approve treatments like TMS and Spravato if you have either experienced positive results from them in the past, or have tried more typical medications first. Providing as much detail as possible about your medication history will assist us in obtaining approval for your treatment.

Medication List

Row ID	Medication	Dose (mg)	Actions

There are no Medications.

Are there any other psychotropic medications that you have tried that were not listed on this form?

Yes

Please list any other psychotropic medications you have tried

Medical History

Do you have a history of any seizures?(Required)

Yes

What type of seizure disorder do you have?(Required)

How frequently do you have seizures?(Required)

Do you have a history of traumatic brain injury?(Required)

Yes

Describe your Traumatic Brain Injury(Required)

Have you been diagnosed with dementia?(Required)

Yes

What type of dementia are you diagnosed with?(Required)

When were you diagnosed with dementia?(Required)

Have you been diagnosed with diabetes?(Required)

Yes

What type of diabetes do you have?(Required)

When were you diagnosed with diabetes?(Required)

Are you on medication for high blood pressure?(Required)

Yes

What is the blood pressure Medication and dosage?(Required)

Do you have any of the following implants?(Required)

Do you have a history of self-harm?(Required)

Yes

Have you ever attempted suicide?(Required)

Yes

Do you have a history of violence towards others?(Required)

Yes

Do you have any known allergies?(Required)

Yes

Please list any known allergies(Required)

CAPTCHA

Pre-Assessment Questions

Patient Information

Medication

Medical History

Are you looking for TMS & Brain Health?