NBCG thanks you for your interest in Transcranial Magnetic Stimulation, which is an FDA-approved treatment for adults suffering from significant major depressive disorder that has not adequately responded to medication and therapy. TMS can also be helped in treating OCD. If you believe you are experiencing treatment-resistant depression, plus or minus OCD symptoms, and would benefit from TMS treatment, please complete the following form. This allow us determine if TMS is the right next step for your healing journey and to review benefits and coverage:

Name *

First Name

Last Name

Birthdate *

Must be 18 or older

YYYY

Phone Number *

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

Policy Number *

Group Number *

Policy Holder Name (If different)

Permission to contact insurance? *

Yes

How long have you had depression? *

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

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

Yes

If you answered yes to the previous question, please list each of the medications, the date you started taking them, your dosage, how long you took each as well as any outcomes and/or side effects

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

Yes

If so, has it had lasting positive effects?

Yes

Do you have any of the following contraindication to TMS: 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

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

Yes

If you answered yes to the previous question, when? *

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

Yes

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

Yes

Please specify what kind and what type of metal.

Do you have diagnosed OCD? *

Yes

Do you suspect that you may suffer from OCD symptoms? *

Yes (if you select yes, please also complete our OCD Screener which can be found under "Forms" above)

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

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

IMPORTANT: Once you submit this form please also complete the PHQ 9 form (which can be found under "Forms" above). This is a required depression assessment required by insurance companies.

Find a Qualified Mental, Behavioral (ABA), Speech or Psychiatric Medical Provider Located Near You.

The well-being and success of every patient is our top priority.

For over 10 years, we’ve supported families, children, teens & individuals across Northern Utah.
We look forward to helping you and your loved ones achieve their goals.

Bountiful
Autism Services (ABA) , Mental Health,
Speech Therapy & Medical Clinic

415 S. Medical Dr.
Suite A100
Bountiful, UT 84010

Layton
Mental Health Clinic

920 West Heritage Park Blvd.
Suite 210
Layton, UT 84041

Salt Lake City
Mental Health Clinic

370 E South Temple
Suite 175
Salt Lake City, UT 84111

Ogden
Autism Services (ABA) &
Speech Therapy Clinic

5974 S. Fashion Pointe Dr.
Suite 140
South Ogden, UT 84403

West Jordan
Autism Services (ABA) Clinic

7613 S. Jordan Landing Blvd.
Suite 120
West Jordan, UT 84084

Ogden
Mental Health & Medical Clinic

5926 S. Fashion Pointe Dr.
Suite 120
South Ogden, UT 84403

Logan
Autism Services (ABA) Clinic

429 Main Street
Logan, UT 84321

CONTACT US

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