Full Name

Email Address

Date of Birth (MM/DD/YYYY)

Phone

Insurance Carrier

Insurance Policy # / Group #

Is Your Insurance a Medicare Plan? Is Your Insurance a Medicare Plan?YesNo

ZIP Code

Any history of seizures? Any history of seizures? Yes No

For which of the following have you been diagnosed? For which of the following have you been diagnosed? Major Depressive Disorder (MDD) Anxiety Disorder Bipolar Disorder None of the above

Have you tried prescription medications? Have you tried prescription medications? Yes, too many to count Yes, 4-7 different types of medications Yes, 1-3 different types of medications No

Any metal implanted in or around the head? Any metal implanted in or around the head? Yes No