New Directions - Website - TMS Web Screening Tool

1
Do you have a diagnosis of depression?
YESNO
2
Are you suffering from depression now?
YESNO
3
For insurance to cover TMS treatment, you must have severe depression. If your depression is well controlled right now, TMS will not be covered by your insurance. New Directions Mental Health does have self-pay options for consideration, as well as mental health counseling or psychiatric medication management services as alternatives.
4
I'm Interested in self-pay for TMS Therapy.
YESNO
5
New Directions Mental Health has many different treatment options available for you including Therapy and Psychiatry options. Please fill out our new client appointment form to get started.

New Client Appointment
6
How many medications have you tried for your depression?
0-1
2-4
5+
7
Have you tried any therapy for your depression?
No
Yes, but fewer than 8 sessions.
Yes, for 8 sessions or more.
8
Is Optum your current insurance carrier?
YESNO
9
Insurance will typically not approve TMS in the absence of a history of medication trials for depression, and usually a history of therapy as well. New Directions Mental Health does have self-pay options for consideration, as well as mental health counseling or psychiatric medication management services as alternatives.
10
I'm Interested in self-pay for TMS Therapy.
YESNO
11
New Directions Mental Health has many different treatment options available for you including Therapy and Psychiatry options. Please fill out our new client appointment form to get started.

New Client Appointment
12
You may be appropriate for TMS and eligible for your insurance to cover it. The next step is to schedule a psychiatric TMS evaluation to confirm that TMS is both safe and appropriate for you.
13
What Insurance do you have?* This field is required.
14
Name* This field is required.
First Name
Last Name
15
Email* This field is required.
example@example.com
16
Phone Number* This field is required.
Please enter a valid phone number.
17
Date of Birth* This field is required.
Date
Year
Month
Day
18
Did a medical professional recommend our services to you?* This field is required.
YESNO
19
Referring Organization Name* This field is required.
20
How did you hear about us?* This field is required.
Please Select
Please Select
Direct Mail / Flyer
Google / Internet Search
Health Insurance Directory
Returning Patient
Clinic Signage
Billboard
Social Media
Referred from Hospital
Referred from Primary Care Doctor / Pediatrician
Referred from Specialty Doctor (OB-GYN, Chiropractor, etc)
Referred from Psychiatrist
Referred from Therapist
Referred from Friend / Family Member
Referred from School
21
Nearest Clinic* This field is required.
Please Select
Please Select
Fox Chapel
Greensburg
McMurray
Meadowlands
Monongahela
Monroeville
Robinson
South Hills
Washington
Wexford
22
What is the best day(s) to reach you?
Monday
Tuesday
Wednesday
Thursday
Friday
23
What is the best time to reach you?* This field is required.
Please Select
Please Select
8:00 am - 10:00 am
10:00 am - 12:00 pm
12:00 pm - 2:00 pm
2:00 pm - 4:00 pm
4:00 pm - 6:00 pm
6:00 pm - 8:00 pm
24
By Submitting this form, you are permitting Northeast Health Services to contact you by phone, email and text.

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