1. Patient Information

• ☐Patient full name
• ☐Date of birth (must be 18 or older)
• ☐Phone number and email address
• ☐Current address

2. Treatment-Resistant Depression Criteria

• ☐Patient has tried 2 or more antidepressants at adequate dose and duration without sufficient relief
• ☐List of medications tried (name, dose, duration, response)
• ☐Current medications and dosages
• ☐Any prior TMS, ECT, or ketamine treatment (include dates and response)

3. Clinical History

• ☐Primary diagnosis (ICD-10 code)
• ☐Comorbid psychiatric conditions (anxiety, OCD, PTSD, bipolar, etc.)
• ☐History of seizures or epilepsy
• ☐Family history of seizures
• ☐Bipolar disorder diagnosis (note: relevant for treatment selection)
• ☐Current or past substance use

4. Contraindications to Screen For

• ☐Metal implants in or near the head or neck (e.g., aneurysm clips, cochlear implants, deep brain stimulators)
• ☐Pacemaker or implanted medical device
• ☐Increased intracranial pressure
• ☐Pregnancy (if applicable)
• ☐Any MRI contraindications (required for SAINT protocol fMRI mapping)

5. Insurance & Logistics

• ☐Insurance provider name and member ID
• ☐Prior authorization history (if any)
• ☐Patient able to arrange transportation home after treatments
• ☐For SAINT: patient able to commit to 5 consecutive days (Mon–Fri, ~10 hrs/day)
• ☐For standard TMS: patient able to attend sessions 5x/week for 6–9 weeks

6. Referring Provider Information

• ☐Referring physician name and credentials
• ☐Practice name and address
• ☐Phone and fax numbers
• ☐NPI number
• ☐Signature and date

Referring Provider Signature

Signature

Date

Neuro Wellness Clinical Use Only

Received by

Consultation date