Preconsultation Form

Education*
- Graduated High School
- Technical Training
- Some College
- College Graduate
- Graduate education
- Other
Are you employed?*
- Yes
- No
- I have a disability that prevents me from working
Where are you employed?*
I have been disabled since and due to:*
I have been unemployed since:*

Where were you born?*
Who raised you during your childhood?*
Do you have any family members with psychiatric disorders or substance use? If so, what kind of treatment have they had?*
Any family history of suicide or suicide attempt?*
Have any of your family members been hospitalized in a psychiatric clinic?*
Any family history of treatment with ECT or TMS?*

If you have had surgery, list the date(s) and type of operation(s)*
Date Type of Operation

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List any current medical conditions*

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Do you have a history of past seizures or epilepsy?*
- Yes
- No
When is the last time you had a physical exam or "check-up" with a primary care doctor?*
Do you have any metal surgically implanted or embedded in your body?*
- Yes
- No

How old were you when you first experienced symptoms?*
Describe the symptoms*
When did you first get treatment?*
Age or year
Describe first treatment (age or year; medication or therapy)*
Do you have a history of prior ECT or TMS treatment? If yes, please indicate below:*
Treatment (ECT or TMS) Dates Where did you obtain treatment? Number of treatments Response

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Please indicate any and all of the psychiatric medications you have taken for your depression*

Medication	Max Dose	Estimated Start Date	Estimated Duration	Response	Side Effects	Write Yes if Current

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Have you had any history of non-medication interventions?*
- Past Outpatient Psychotherapy
- Intensive Outpatient or Partial Hospital Programs
- Hospital Admission(s) for Psychiatric Care
- Hospital Admission(s) for drug/alcohol detox
- Drug/Alcohol Rehab programs
- Research/investigational treatments (i.e. Ketamine, tDCS, etc.)
Please describe any history of non-medication interventions
Please give as much detail as you can (Dates, Names, Focus of Care).
Past Outpatient Psychotherapy*
Include name, dates of treatment, and type of treatment (i.e. CBT, Interpersonal, Psychodynamic, etc.)
Intensive Outpatient of Partial Hospital Programs*
Hospital Admission(s) for Psychiatric Care*
Hospital names and dates
Hospital Admission(s) for drug/alcohol detox*
Drug/alcohol rehab programs*
Research/investigational treatments*
i.e. Ketamine, tDCS, etc.
Even if no treatment has ever fully resolved your depression, which treatment has worked BEST for relieving symptoms?*
Have you ever experienced full recovery (completely better for at least a year) from an episode of depression? If yes, please describe:*

Please rate your Mental Health and Functioning Level on this scale:*
Current rating Highest rating you've ever experienced
(0 = Worst ever…..100 = ”Normal” or optimal mental heath)
Anything else you think I should know?*

Prescribing Psychiatrist

Treatment (ECT or TMS)	Dates	Where did you obtain treatment?	Number of treatments	Response

Date	Type of Operation