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Self Assessment

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Self Assessment

Find out if ReNu Deep TMS is right for you. Fill out our self assessment below and we’ll be in touch.

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Name *

First

Last

Email *

Phone *

How do you prefer to hear from us? *

Phone
Text
Email

Have you ever been diagnosed with major depression? *

Yes
No

Have you ever been diagnosed or treated for bipolar disorder? *

Yes
No

Have you ever been diagnosed or treated for schizoaffective disorder or schizophrenia? *

Yes
No

Do you have a metal implant in or around the head? *

Yes
No

Do you have a defibrillator or pacemaker implanted? *

Yes
No

Do you have a seizure disorder/epilepsy? *

Yes
No

Have you been through at least 6 weeks of counseling or psychotherapy? *

Yes
No

How many antidepressant or mood stabilizers have you tried? *

0
1
2
3
4 or more

Will you be going through insurance? *

Are you interested in a discussion regarding cash payments for TMS Services? *

Yes
No
Maybe

Have you had a previously successful trial of TMS Therapy? *

Yes
No

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