View Clinician Referral & Co-Management Guide

Clinician Resource · One-Page Referral Form

Physician Referral & Patient Eligibility Checklist

Use this clinically approved checklist to identify appropriate candidates for SAINT® accelerated TMS (50 sessions over 5 days, fMRI-guided), conventional daily TMS (6–9 weeks), and SPRAVATO® (esketamine). Final clinical eligibility is determined during medical consultation by our medical director, Daniel Pietras, MD.

Read Co-Management Protocol

Step 1

Clinical Intake

Review referral records & preliminary telehealth/phone screening

Step 2

fMRI Brain Mapping

Resting-state functional MRI to calculate individual sgACC-dlPFC target

Step 3

5 Treatment Days

10 daily iTBS sessions on Magnus System (50 total) Monday–Friday

Step 4

Clinical Handback

Full completion report & return to referring provider for care

Clinician Instructions: Complete this checklist to expedite your patient's evaluation. Fax completed form along with recent psychiatric notes, medication history, and current labs (if available) to our confidential intake fax at 954-827-9793. We maintain strict non-retention of patients: our role is specialized neuromodulation delivery; long-term medication and psychotherapy management remains with your practice.

1. Patient Demographics & ContactCheck all that apply

☐Patient full legal name and date of birth (must be 22 or older for FDA-cleared SAINT®; 18+ for standard TMS / SPRAVATO®)
☐Primary phone number, mobile number, and email address
☐Current residential address
☐Preferred language (English / Spanish — bilingual clinical staff available)

2. Diagnosis & Treatment-Resistant Depression HistoryCheck all that apply

☐Primary psychiatric diagnosis with ICD-10 code (e.g., F32.1, F32.2, F33.1, F33.2 Major Depressive Disorder)
☐Patient is currently experiencing a major depressive episode
☐List of prior antidepressant trials (minimum 2 adequate trials of differing classes at therapeutic dose for ≥6–8 weeks)
☐Trial details: medication name, maximum dose, duration, response, and reason discontinued (inefficacy vs. intolerable side effects)
☐Prior psychotherapy trials (CBT, psychodynamic, etc.) and clinical response
☐History of prior neuromodulation (standard TMS, ECT, VNS) or ketamine/SPRAVATO® therapy with dates and response

3. Current Clinical Status & ComorbiditiesCheck all that apply

☐Current psychiatric medications, doses, and prescribing clinician
☐Comorbid conditions documented (generalized anxiety, OCD, PTSD, panic disorder)
☐Absence of active bipolar I disorder or current/recent psychotic symptoms (unless co-managed and clinically cleared)
☐Substance use history: active severe substance use disorder must be stabilized prior to intensive outpatient protocol
☐Baseline depression severity rating (PHQ-9, MADRS, or HAM-D score within past 30 days)

4. Critical Safety Screening & ContraindicationsCheck all that apply

☐NO non-removable ferromagnetic metal in or within 30 cm of the head (aneurysm clips, cochlear implants, deep brain stimulators, metal plates, ocular metallic fragments)
☐NO implanted medical devices controlled by physiological signals (cardiac pacemakers, ICDs, vagus nerve stimulators, medication pumps)
☐NO history of unprovoked seizures, epilepsy, or known increased intracranial pressure
☐Patient is NOT currently pregnant (unless cleared by treating obstetrician and psychiatrist after risk-benefit discussion)
☐Patient is eligible and safe for 3T MRI scanning (required for individualized fMRI-guided target selection on the Magnus System)

5. Protocol Commitment & LogisticsCheck all that apply

☐SAINT® protocol commitment: patient able to attend 5 consecutive business days (Monday–Friday, ~9:00 AM – 5:30 PM, 10 sessions/day with 50-minute rest intervals)
☐Standard TMS alternative: patient able to attend 1 session/day, 5 days/week for 6–9 weeks (~36 sessions total)
☐Transportation: patient arranged daily transport to/from clinic (no sedation is used; patients can drive themselves, but travel companions are welcomed)
☐For out-of-town patients: confirmed travel plan to Coral Springs, FL clinic with accommodations arranged

6. Referring Clinician & Co-Management InformationCheck all that apply

☐Referring provider full name, title, credentials, and specialty
☐Practice name, clinic address, direct phone, and secure HIPAA fax number
☐National Provider Identifier (NPI) number and state medical license number
☐Preferred communication method for progress reports and post-treatment clinical handback summary

7. Relevant Clinical History & Specific Questions for Neuro Wellness

Our Co-Management & Handback Commitment to Referring Providers:Neuro Wellness TMS Centers of America provides interventional treatment only. Within 5 business days of treatment completion, our clinical team faxes a formal handback summary to your office detailing: (1) baseline and post-treatment psychometric scores (PHQ-9 / MADRS), (2) exact treatment parameters delivered (50 sessions, fMRI coordinates, motor threshold), (3) tolerability and side-effect summary, and (4) clinical recommendations for maintenance. Your patient returns directly to your care for ongoing pharmacotherapy and psychotherapy.

Referring Provider Attestation & Signature

Provider Signature & Credentials (MD / DO / NP / PA)

Date & Direct Contact Phone

Neuro Wellness Intake Review (Internal Use Only)

Received & Reviewed By

Physician Consultation Scheduled Date

How to Submit This Referral Securely

To protect protected health information (PHI), please do not submit patient clinical history through public web forms. Use our secure HIPAA clinical channels:

Confidential Clinical Fax: 954-827-9793

Physician-to-Physician Line: 954-827-9793

Facility: 9734 W Sample Rd, Ste B, Coral Springs, FL 33065

Response Time: Referring office contacted within 1 business day

Emergency / Acute Crisis Notice: If your patient is experiencing acute suicidal ideation with intent or psychiatric emergency, direct them to the nearest emergency department or call/text 988 (Suicide & Crisis Lifeline, 24/7). Neuro Wellness is an outpatient facility and does not provide emergency psychiatric crisis stabilization.

Need to discuss a complex case before referring?

Our clinical team welcomes peer-to-peer discussions regarding candidacy and fMRI targeting.

Call 954-827-9793

Clinician & Referral Resources

Clinician Guide: Refer a Patient for SAINT®

Detailed referral workflow, co-management protocol, and fMRI targeting requirements.

What Is a Verified SAINT® Provider?

Five verification checks confirming genuine Magnus Medical technology.

SAINT® Protocol: 50 Sessions in 5 Days

Full clinical parameters, dosing, and session schedules.

SAINT® TMS Cost & Insurance Guide

Self-pay rates, insurance prior authorization, and benefits verification.

SAINT® Accelerated TMS

FDA-cleared, 5-day accelerated TMS protocol

Standard TMS Therapy

Non-invasive magnetic stimulation for depression

Physician Referral & Patient Eligibility Checklist

Neuro Wellness TMS Centers of America