Refer a Patient - Greenbrook TMS

Working together giving patients hope

Greenbrook TMS accepts all major insurance. Medicare & Medicaid accepted at various locations. Call 855-940-4867 to find a nearby location.

If you are requesting a Consultation for yourself or a loved one, please use this form.

To Refer a Patient:

Print, sign, and fax the referral form below to 855-721-4867

Patient Name:

Gender

Patient Phone Number:

Patient Date of Birth:

Patient Zip Code: *

Contact Name (if someone other than the patient):

Contact Phone Number:

Relationship to Patient:

Primary Diagnosis:

Has the patient tried 4 or more anti-depressant medications?

Yes
No

Has or is the patient engaged in any psychotherapy?

Yes
No

Does the patient have any history of seizure?

Yes
No

Does the patient have any metallic implants above the neckline (not including dental implants)?

Yes
No

Additional Notes:

Referring Provider Name:

Referring Provider Phone Number:

Referring Provider Email Address:

Referring Provider Practice Location:

Referring Provider Speciality:

About TMS Therapy

Transcranial Magnetic Stimulation Therapy (TMS Therapy) is a safe and effective treatment for those diagnosed with MDD who have not experienced satisfactory relief with their antidepressant medication. It can be used in conjunction with medication or as a stand-alone treatment; this makes it an effective treatment option for those who cannot take antidepressants or cannot tolerate their side effects.

TMS Therapy applies targeted magnetic pulses to areas of the brain involved in mood regulation, areas that researchers have identified in brain scan imaging to be underactive in people diagnosed with depression. Magnetic pulses activate neurons, thereby improving the brain’s ability to regulate mood.

Typical Course of Treatment

Although treatment varies by individual, a typical treatment course consists of:

Average of 20–36 treatment sessions
Conducted over a 6–9 week period
5 treatments per week
Each treatment session lasts approximately 18–20 minutes

Benefits

FDA Cleared & Proven – 2 out of every 3 patients had a reduction in depression scores after a 4-week treatment period
Non-Sedating – patient remains awake and alert during treatment and can resume usual routine, including driving
Non-Drug – no drug related side effects such as weight gain, drowsiness, nausea, insomnia, gastrointestinal distress and decreased libido
Non-Systemic
Non-Invasive

Upon Referral, Patient should expect:

Complimentary Consultation: Scheduled by patient at a conveniently located Greenbrook TMS Center. During the consultation, patients learn more about TMS Therapy. Their relevant medical history will be discussed, including prior / current medications and psychotherapy.
Pre-Assessment: Conducted by a Greenbrook Medical Director, psychiatrists with specialized training in TMS Therapy, to determine your patient’s candidacy for treatment.

If your patient qualifies for TMS Therapy, you will recieve:

Treatment Commencement Confirmation
Treatment Summary at the conclusion of patient's TMS treatment