Referral Form

Referral Form Transcranial Magnetic Stimulation (TMS)

Patient Information

Name*DOB*

Address*

Phone*Other PhoneEmail

Medicare status (if known)

Non-concessionConcessionNon MedicareReached safety net (if Medicare)

Reason for Referral (tick all that apply)Initial TMS course with MRI-guided neuronavigation for Treatment-Resistant Depression (TRD)Re-treatment TMS course following initial TMS courseBooster TMS course following a previous TMS courseTMS course for non-TRD major depressive disorder or where patient does not satisfy Medicare eligibility criteriaTMS course for TRD without MRI-guided neuronavigation due to MRI being unsuitable for this patientPsychiatric reviewOther (specify)

Medicare Rebate Eligibility Criteria for Treatment-Resistant Depression (TRD)Have not received TMS previously (if initial course)Diagnosed with major depressive disorderNo significant improvement after trialling at least 2 classes of antidepressant medications at therapeutic doses for at least 3 weeks, unless contraindicatedOver 18Undertaken psychological therapy if clinically requiredReceived initial TMS course more than 4 months ago (if re-treatment course)

Mental Health History

Including details of any prior TMS response (if applicable) and response to any other interventions trialled.

Medical History

Including whether there is any history of seizures, cochlear implant, intracranial implants, brain surgery, hearing impairment or substance abuse.

Referring Doctor Information

Name*Email*Medical Provider No*Address*Phone*Date

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Referral Form Transcranial Magnetic Stimulation (TMS)

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