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HomePreconsultation Form

Preconsultation Form

Step 1 of 12 - Basic Information

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  • Prescribing Psychiatrist

  • Best Estimate
  • Therapist

  • Best Estimate
  • Primary Care Physician

  • Best Estimate
  • DateType of Operation 
    Use the plus (+) icon to add new items
  • Use the plus (+) icon to add new items
  • Age or year
  • Treatment (ECT or TMS)DatesWhere did you obtain treatment?Number of treatmentsResponse 
    Use the plus (+) icon to add new items
  • MedicationMax DoseEstimated Start DateEstimated DurationResponseSide EffectsWrite Yes if Current 
    Use the plus (+) icon to add new items
  • Please describe any history of non-medication interventions

    Please give as much detail as you can (Dates, Names, Focus of Care).
  • Include name, dates of treatment, and type of treatment (i.e. CBT, Interpersonal, Psychodynamic, etc.)
  • Hospital names and dates
  • i.e. Ketamine, tDCS, etc.
    Check all that apply
  • Current ratingHighest rating you've ever experienced
    (0 = Worst ever…..100 = ”Normal” or optimal mental heath)
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