Name *

First Name

Last Name

Birthdate *

Must be 18 or older

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Provider *

Select Health

Regence/Blue Cross

WISE

Tricare

Health Utah Network

Self Pay

Optum

Secondary Insurance Provider *

Select Health

Regence / Blue Cross

WISE

Tricare

Health Utah Network

Self Pay

Optum

Permission to contact insurance? *

Yes

No

Do you have a history of and current significant symptoms of depression such as: hopelessness, irritability, and sadness, , feelings of worthlessness, decreased or increased appetite, trouble sleeping, restlessness, motoric slowing, fatigue, worthlessness, concentration issues, or thoughts of death. *

Yes

No

Have you been treated with over 3 anti depressant medications with no significant positive lasting effects and or intolerable side effects? (These will need to be verified) *

Yes

No

Have you received effective mental health therapy to treat your depression? *

Yes

No

If so, has it had lasting positive effects?

Yes

No

Do you have any of the following contraindicators: Active or inactive implants in your head, (deep brain stimulators, cochlear implants, etc.) rapid onset psychoses, history of seizures, or epilepsy, traumatic brain injury? *

Yes

No

Have you ever been diagnosed by a doctor/medical professional with Major Depression? *

Yes

No

Are you struggling with substance abuse? Substance abuse could affect the outcomes of treatment. *

Yes

No

Do you have metal in or around your head (earrings, facial piercings, facial tattoos, permanent makeup, plates, screws, etc.) ? *

Yes

No

Treatment length is typically 6 weeks, daily for 20-30 minutes. If approved, what would your requested start day be? *

MM

DD

YYYY

How did you hear about us?

Friend or Family Member

Primary Care Physician

Other Provider Referral

Social Media (Facebook, Instagram)

Google Search Engine

Other