BioMental Consult

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Patient Information

Patient First Name Patient Last Name Patient Date of Birth Patient Email Patient Phone Number Location

Appointment Request

Referral And Care Team

Were you referred by a provider?

Yes No

Name of Current Therapist Name of Current Primary Care Provider (PCP)

Current Medications

Medication 1

Insurance

Primary Insurance Provider Insurance Policy Number Primary Insurance Card

Do you have secondary insurance?

Yes No

Treatment History

Have you done TMS previously?

Yes No

Have you tried SPRAVATO previously?

Yes No

For your evaluation, which option do you prefer?

Telehealth Appointment In-person Appointment

Prior Medication History

Which SNRIs have you taken in the past?

Safety And Therapy History

Do you have a history of any of the following:

Are you currently in or have you ever tried talk therapy?

Yes No

Do you have any of the following implants:

Person Completing This Form

Are you completing this form on behalf of someone else?

Yes No

Request a Consult

Patient Information

Appointment Request

Referral And Care Team

Current Medications

Insurance

Treatment History

Prior Medication History

Citalopram (Celexa)

Escitalopram (Lexapro)

Paroxetine (Paxil)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Sertraline (Zoloft)

Venlafaxine (Effexor)

Duloxetine (Cymbalta)

Desvenlafaxine (Pristiq)

Levomilnacipran (Fetzima)

Vilazodone (Viibryd)

Vortioxetine (Trintellix)

Buproprion (Wellbutrin)

Buspirone (Buspar)

Lithium (Eskalith)

Trazodone

Mirtazapine (Remeron)

Selegiline (Emsam)

Adderall

Spravato

Lamictal (lamotrigine)

Depakote (valproate)

Tegretol (carbamazepine)

Abilify (aripiprazole)

Rexulti (brexpiprazole)

Risperdal (risperidone)

Seroquel (quetiapine)

Vraylar (cariprazine)

Zyprexa (olazepine)

Safety And Therapy History

Person Completing This Form