Pre-Assessment Pre-Assessment Questions Patient InformationName(Required) First Last Email(Required) Phone(Required)For what reason are you seeking treatment?What is your date of birth?(Required) MM slash DD slash YYYY On a scale of 1 through 10, how stressful is your living environment?Please select12345678910On a scale of 1 through 10, how supportive is your living environment?Please select12345678910Which locations are you interested in?(Required) Santa Monica/West LA Downtown Los Angeles Las Vegas Virtual IOP (CA only) What is the name of the individual filling out this form? What is your address? Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Marital Status Married Divorced In a relationship Single Widowed Employment Status Full Time Part Time Retired Unemployed Education Level Diploma High School Diploma Some College College Degree Graduate Degree Which of the following treatments will you be interested in being evaluated for?(Required) IV Ketamine Spravato esketamine nasal spray Transcranial Magnetic Stimulation (TMS) Therapy Accelerated TMS Intensive Outpatient Program (IOP) If you are requesting services for treatment resistant depression, when did the treatment resistant depression begin? MM slash DD slash YYYY Do you have any current medical diagnoses? Yes No What are your current medical diagnoses?DiagnosisDate Diagnosed Add RemoveHave you received mental health treatment before? Yes No Please list the name of the clinic or provider that you've received treatment at in the past.ProviderProvider PhoneTreated ForDate Treated Add RemovePlease include provider phone, dates you were treated, and what you were treated forAre you currently under the care of a psychiatrist? Yes No Psychiatrist name Psychiatrist phonePlease include dates you were treated, and what you were treated for by the above psychiatristTreated ForDate Treated Add RemoveAre you currently in or have you ever tried psychotherapy or counseling?(Required) Yes No What is the name of your most recent therapist or counselor? Approximately when did you start seeing the above therapist or counselor? MM slash DD slash YYYY Approximately when did you stop seeing the above therapist or counselor? MM slash DD slash YYYY Do you plan on using your insurance? Yes No What is your insurance?Please selectAetnaAetna Medicare PlanBlue Cross of CaliforniaBlue Shield of CaliforniaBlue Cross FederalMagellan BehavioralCignaUnited HealthcareUnited Behavioral HealthUnited Healthcare Student ServicesMHNMedicare of Southern CAMeritain HealthOxford Health PlanBeacon Health OptionsOscar Health PlanPalmetto GBA MedicareUMRTufts Health PlanAccendoCompsychWrite in if not availableInsurance Member ID MedicationCollecting 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 Edit Delete There are no Medications. Add Medication Maximum number of medications reached. Are there any other psychotropic medications that you have tried that were not listed on this form? Yes No Please list any other psychotropic medications you have triedMedical HistoryDo you have a history of any seizures?(Required) Yes No 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 No Describe your Traumatic Brain Injury(Required)Have you been diagnosed with dementia?(Required) Yes No What type of dementia are you diagnosed with?(Required) When were you diagnosed with dementia?(Required) MM slash DD slash YYYY Have you been diagnosed with diabetes?(Required) Yes No What type of diabetes do you have?(Required) When were you diagnosed with diabetes?(Required) MM slash DD slash YYYY Are you on medication for high blood pressure?(Required) Yes No What is the blood pressure Medication and dosage?(Required) Do you have any of the following implants?(Required) N/A Cardioverter defibrillator Metal aneurysm clips, coils, staples, or stents Cochlear implants Vagus nerve stimulator Pacemaker Any other metal implants in the head/skull Do you have a history of self-harm?(Required) Yes No Have you ever attempted suicide?(Required) Yes No Do you have a history of violence towards others?(Required) Yes No Do you have any known allergies?(Required) Yes No Please list any known allergies(Required)CAPTCHA Δ
