TMS Eligibility Form new

Insurance or Self-Pay*

Do you suffer from Depression? YesNo

If Yes, when did your current depressed episode start?

Have you taken any medications to treat your depression? YesNo

If yes, please fill out fields below.

Medication Name

Max Dosage

Start Date
MM/YYYY

Stop Date
MM/YYYY

Helpful? YesNo

Side Effects?

Have you seen a counselor/therapist during your current depressed episode? YesNo

If yes, please fill out below fields

Counselor’s Name (LPC, LCSW, PhD…)

Start Date
MM/YYYY

Stop Date
MM/YYYY

Frequency? (daily, weekly…)

Benefits?

Do you have, or have you ever had, any of the following? If yes, please explain.

1. Any metal on or in your body/brain above the waist? YesNo

2. Cardiac pacemaker YesNo

3. Implanted medication pumps, or central venous catheter YesNo

4. History of brain injury such as a stroke or tumor YesNo

5. Prior diagnosis of seizure or epilepsy YesNo

6. Previous brain neurosurgery YesNo

7. Are you pregnant or is there a chance you could be pregnant? YesNo

8. Can you come into the office daily for six weeks for treatment? YesNo

My signature below indicates that I have read, understand, and accurately answered all questions in this document.

Cedar Park TMS

Brian S. Earthman, MD, is a psychiatrist and addiction medicine specialist focusing on adult mental health and substance abuse treatment. Dedicated to ensuring patients experience whole health after treatment, Dr. Earthman’s goal is to guide patients to wellness using a comprehensive treatment approach that includes TMS, medication, counseling, and Alpha-Stim™ therapy. He has been certified and trained by the Clinical TMS Society (CTMSS) since 2018. Dr. Earthman graduated from the University of Texas at Austin, receiving a bachelor’s degree in biology. He then attended Texas Tech School of Medicine, where he received his medical degree. Dr. Earthman completed his residency in the department of psychiatry at the University of Texas Health Science Center in San Antonio in 2005. He is also a diplomat of the American Board of Addiction Medicine.

Cedar Park TMS

11901 W Parmer Ln
#310 B
Cedar Park, TX 78613

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Phone : (512) 265-0429

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