Apply for TMS, Spravato (Ketamine), or the Program

    Your Full Name *
    Your Email *
    Your Phone Number *
    Insurance Provider *
    Have you tried TMS before? *
    YesNo
    Are you currently in or have you ever tried talk therapy? *
    YesNo
    Which SSRIs have you taken in the past? Please include relevant dosages, medication duration, and any side-effects you may have experienced:
    Citalopram (Celexa)Escitalopram (Lexapro)Paroxetine (Paxil)Fluoxetine (Prozac)Fluvoxamine (Luvox)Sertraline (Zoloft)
    Which other anti-depressants have you taken in the past? Please include relevant dosages, medication duration, and any side-effects you may have experienced:
    Vilazodone (Viibryd)Vortioxetine (Trintellix)Buproprion (Wellbutrin)Buspirone (Buspar)Lithium (Eskalith)TrazadoneMirtazapine (Remeron)Selegiline (Emsam)AdderallSpravato
    Which atypical antipsychotics have you taken in the past? Please include relevant dosages, medication duration, and any side-effects you may have experienced:
    Lamictal (Lamotrigine)Lurasidone (Latuda)Quetiapine (Seroquel)Aripiprazole (Abilify)Brexpiprazole (Rexulti)Olanzapine (Zyprexa)Risperidone (Risperdal)
    What dosage of Brexpiprazole (Rexulti) did you take?
    Which SNRIs have you taken in the past? Please include relevant dosages, medication duration, and any side-effects you may have experienced:
    Venlafaxine (Effexor)Duloxetine (Cymbalta)Desvenlafaxine (Pristiq)Levomilnacipran (Fetzima)
    When did you start taking Brexpiprazole (Rexulti)?
    When did you stop taking Brexpiprazole (Rexulti)?
    Did you experience any side-effects from Brexpiprazole (Rexulti)? If so, what were they?
    Do you have a history of any of the following:
    SeizuresCerebrovascular diseaseDementiaIncreased intracranial pressureTraumatic brain injuryNone of the above
    Do you have any of the following implants:
    Cardioverter defibrillatorMetal aneurysm clips, coils, staples, or stentsCochlear implantsVagus nerve stimulatorPacemakerNone of the above