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Refer A Patient

1) Have you ever sought professional help, counseling, or therapy for your depression before? *

Yes, currently Yes, in the past No No, but I want to

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2) Have you ever taken any antidepressants before? *

Currently taking one or more 6–12 months ago 12–24 months ago More than 24 months ago No medication Not sure

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3) Is your current medication failing to provide adequate relief from your depression? *

Yes Partial No Not sure

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4) Do you have any metal implants above the shoulders (except for braces and dental fillings)? *

No metals above the shoulder whatsoever Aneurysm clips or coils Stents in the neck or brain Deep brain stimulators Shrapnel or bullet fragments in or near the head Other metal devices or object implanted in or near the head

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5) What is your age range? *

18–29 30–49 50–64 65 or above Below 18

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6) What is your gender? *

Female Male Non-binary Rather not say

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Who do we send the results to?

Well done completing this quiz; we applaud your courage in pursuing happiness.

We will never spam or sell your information. Your data is protected in full compliance with HIPAA. By submitting this quiz, you agree to receive an email with your results from NeuroStim TMS.

First Name *

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