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or contact a therapist at Kayenta directly to schedule your in-office or teletherapy session today!
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Improve your overall wellbeing by starting
Deep TMS treatments
today!
Complete the screening form below to get a free consultation. You can also complete it over the phone with one of our staff members.
(702) 438-7800
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This field is for validation purposes and should be left unchanged.
Name
(Required)
First
Last
Birthdate
(Required)
MM slash DD slash YYYY
Phone
(Required)
Email
(Required)
Insurance Provider
(Required)
Are you currently seeing a Mental Health Therapist?
(Required)
Yes
No
Do you currently see a Psychiatrist?
(Required)
Yes
No
Have you previously tried antidepressants?
(Required)
Yes
No
If Yes, which ones?
Pregnant or Nursing
(Required)
Yes
No
History of Seizures
(Required)
Yes
No
TBI/Brain Injury or Damage
(Required)
Yes
No
Frequent Headaches or Migraines
(Required)
Yes
No
Aneurysm Clips or Coils
(Required)
Yes
No
Stents
(Required)
Yes
No
Deep Brain Stimulator
(Required)
Yes
No
Electrodes (Brain Activity Monitor)
(Required)
Yes
No
Implants in Eyes or Ears
(Required)
Yes
No
Shrapnel or Bullet Fragments
(Required)
Yes
No
Facial Tattoos or Permanent Makeup
(Required)
Yes
No
Cochlear Implants
(Required)
Yes
No
Vagal Nerve Stimulator
(Required)
Yes
No
Magnetic Implants or Other Devices
(Required)
Yes
No
Pacemaker
(Required)
Yes
No
Do you have a history of substance abuse?
(Required)
Yes
No
Do you have a history of suicidal ideation (current episode)?
(Required)
Yes
No
Do you have a history of Psychosis or Psychotic Symptoms?
(Required)
Yes
No
Do you have a history of Obsessive-Compulsive Disorder (OCD)?
(Required)
Yes
No
Have you ever been in individual or group therapy?
(Required)
Yes
No
Have you ever had Transcranial Magnetic Stimulation (TMS)
(Required)
Yes
No
Have you ever had Electroconvulsive Therapy (ECT)
(Required)
Yes
No
Any history of suicide attempts?
(Required)
Yes
No
Have you ever been hospitalized for a psychiatric illness?
(Required)
Yes
No
Have you ever been in an intensive outpatient program?
(Required)
Yes
No
Reason for TMS
(Required)
Depression
OCD
Smoking
Other
Other Reason
What is the best day & time for a phone consultation?
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