Contact Us

Patients Description

Patient Name

Date of birth

Phone

Email

Address

Patients Other Description

Practitioner

PHN

PRACID

Phone#

Fax#

Select type of Application

rTMS

Shared Care

Group Therapy

Repetitive Transcranial Magnetic Stimulation (rTMS) Referral Form

Age 18+

Diagnosis of major depressive disorder, post-traumatic stress disorder, obsessive-compulsive disorder,generalized anxiety disorder or depression secondary to traumatic brain injury/ concussion

Has failed at least 3 antidepressant trials (non-response or intolerance)

Not actively suicidal (requires higher level of care)

No non-removable metallic hardware or devices in the head region (cochlear implants, deep brainstimulators, foreign metal fragments, etc.) - dental hardware is acceptable

No prior history of epilepsy

Depression and anxiety symptoms not deemed primarily caused by substance use

No history of violence/ physical assault towards others

No severe active substance use issues

Referral must include both of the following to be processed:

recent clinical note pertaining to the reason for referral

previous psychiatric consult notes (if available)

(if applicable) patient is under the care of

Dr.

Psychiatrist

Clinical background

(personality traits, suicidality, diagnosis, comorbidities, patient goals):

Download Your Completed Form

Download PDF

All Set! Your Download is Ready!

CONTACT US

All Set!
Your Download is Ready!