Crestpoint Psychiatric Care (TMS treatment; Intranasal Ketamine)

INTAKE FORM to be filled out by the PATIENT ONLY.
Dr. Aimua will review your intake form to determine if we can schedule your appointment. Allow our office 5 business days to verify your insurance benefits, and we will follow up with you regarding an appointment.

NOTE: Office is located at 206 PRINCETON ROAD, STE18, JOHNSON CITY, TN

For the TRANSCRANIAL MAGNETIC STIMULATION (TMS) intake form, please visit our TMS website. https://www.tmsofjohnsoncitytn.com/

Full Name*

Date of Birth*

Email*

Cell Phone Number*

Home Address (Street)*

Home Address (City)*

Home Address (State, Zip Code)*

Insurance Carrier (PRIMARY INSURANCE)*

Member ID*

Who is the person listed as the primary insured?

Self
Spouse
Parent

Full Name and Date of Birth of the primary insured. If this is you, type "self".*

Attach a copy of your insurance card(FRONT)

Attach a copy of your insurance card(BACK)

IF APPLICABLE, attach here a COPY of Power of Attorney/Conservatorship letter.

Do you have more than one health insurance carrier?

YES
NO

This office is NOT IN-NETWORK with MEDICAID/TNCARE/BLUCARE.

Answer each question below

1. REASON for appointment (Medication management, TMS Treatment, Ketamine (intranasal), Consultation, Other).*

For ADD/ADHD request, Dr. Aimua conducts a full psychiatric evaluation and a neurocognitive assessment before making recommendations. Dr. Aimua does not conduct testing for autism spectrum disorder (ASD).

Policy Noted

2. Do you currently have a psychiatrist?

YES
NO

List your CURRENT psychiatric medications.*

4. Are you currently taking medications like Oxycodone, Percocet, Morphine, Lortab, Suboxone, Methadone?

YES
NO

3. Do you have a family member that is a patient here?

YES
NO

5. Are you currently taking Xanax, Klonopin, Valium, Ativan, Librium?

YES
NO

6. IF "YES" to question #5, is this your primary reason for requesting this appointment?

YES
NO

PLS note that you cannot DEMAND that Dr. Aimua prescribe you a BENZODIAZEPINE. Dr. Aimua conducts a full psychiatric evaluation based on which she makes recommendations regarding your Xanax, Ativan, Valium, Klonopin, Temazepam dosage.

Policy Noted

10. Are you being discharged from a Psychiatric hospital, Detox or Rehab facility? (IF "YES", have your discharge summary faxed to 423-631-0047)

YES
NO

11. Are you applying or planning to apply for DISABILITY? (If "YES" NOTE Dr. Aimua does not do disability paperwork)

YES
NO

12. Is this appointment for any legal proceedings (court mandated, divorce, custody, DUI, etc)

YES
NO

Click on the “FAQs” tab on our website for commonly asked questions as you prepare for your appointment.

Noted

Dr. Aimua is board-certified in Psychiatry by the American Board of Psychiatry and Neurology with over fifteen years of clinical experience providing individualized psychiatric care through medication management combined with different psycho-therapeutic interventions to address a broad range of DSM 5 psychiatric syndromes.
Dr. Aimua is an Adjunct Clinical Associate Professor with the ETSU Department of Psychiatry and Behavioral Sciences where she participates in the training of Resident Doctors.

Neurocognitive Testing

Computer based CNSVITALS Neurocognitive Assessment for ADD/ADHD, MCI, MS, TBI

Medication Management

Dr. Aimua provides psychiatric treatment for various DSM 5 psychiatric disorders using a combined approach of medication management with psychotherapy. MAT (Medication Assisted Treatment) for opioid and alcohol use disorders. Gene-sight Genetic Testing: A pharmacogenomic test that analyzes clinically important genetic variations that may impact how the patient metabolizes and responds to certain medications.

TMS Treatment

Numerous studies have demonstrated the safety and effectiveness of TMS in MDD/OCD/Anxiety, especially in treatment-resistant patients who have not responded to medications. Approximately 58% of treatment-resistant patients respond positively to TMS therapy. CLICK ON THE LINK BELOW TO OUR TMS WEBSITE

Learn More

ESKETAMINE Treatment

Dr. Aimua now provides INTRANASAL KETAMINE (SPRAVATO)for treatment for depression. (See below for details)

What should I expect from my first session with the Psychiatrist?

During your first, the Psychiatrist will be asking a lot of questions to try and gain a full understanding of your condition and mental health. It is natural to be anxious about your first meeting but you do not need to be afraid.

Be open about discussing your symptoms. No matter your emotional response to your first psychiatric session, you will find no judgment from your psychiatrist.

It might be easier if you make a list of symptoms that you would like the psychiatrist to know.

The length of the visit varies from person to person. Initial visits are typically scheduled for 1 hour.

Depending on your diagnosis, the Psychiatrist will make treatment recommendations that may include therapy, medications, lifestyle adjustments, and if indicated inpatient treatment.

Can I bring a friend or family member for support?

YES! You will need to sign a consent in the office.

What if I don’t like the Psychiatrist or agree with the recommendations?

If you don't like your psychiatrist, then it is probably best to look for a different mental health provider. It is perfectly normal to not feel comfortable with every Psychiatrist you meet, so don't be afraid to keep looking.

Mental health professionals, like all people, have a wide range of personalities, strengths, and weaknesses, and it's important to find the one who is right for you as an individual.

Our TMS website has detailed answers to FAQs on TMS. Click the link below to review answers to FAQs and submit an INTAKE form for TMS.

https://www.tmsofjohnsoncitytn.com/

What is TMS?
Transcranial magnetic stimulation (TMS) is a medication-free, non-invasive treatment that uses repetitive magnetic pulses to stimulate nerve cells in the brain to improve symptoms of depression.
During a TMS session, an electromagnetic coil is placed against the scalp.
The electromagnet pulse stimulates nerve cells in the region of your brain involved in mood control and depression.

TMS Therapy is typically used when other depression treatments haven’t been effective.

Transcranial Magnetic Stimulation (TMS) is FDA-approved for Major Depressive Disorder and obsessive-compulsive disorder (OCD). It has fewer side effects than most medications and is twice as effective as most meds.
For most people, the effects are lasting, and they stay depression-free for years to come.

It is covered by MOST INSURANCE, including MEDICARE.

Transcranial magnetic stimulation(TMS) image

Click on the video above to watch Tish's testimonial on how TMS changed her life.

What is ESKETAMINE?

KETAMINE (INTRANASAL ESKETAMINE) Intranasal Spray is indicated, in conjunction with an oral antidepressant, for the treatment of:
**Treatment-resistant depression (TRD) in adults.
**Depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior. SPRAVATO (esketamine) is the first and only NMDA receptor antagonist approved for 2 subtypes of MDD in adult patients.
SPRAVATO treatment is covered by most insurance companies.

CONTACT THE OFFICE TODAY TO GET STARTED.

Click on the link below for more information regarding SPRAVATO

https://www.spravatohcp.com/sites/www.spravatohcp.com/files/SPRAVATO-Patient-Brochure.pdf?v=257568

https://www.spravatotreatmentcenter.com/sites/www.spravatotreatmentcenter.com/files/SPRAVATO_Dual_Indication_Product_Fact_Sheet.pdf?v=12

We are in-network with the following health insurance plans. (Pls note we do not accept TennCare/MEDICAID)

BCBS
UNITED HEALTHCARE/OPTUM
UMR
TRICARE
ANTHEM
MEDICARE
CIGNA/EVERNORTH
AETNA COMMERCIAL
AETNA MEDICARE ADVANTAGE
MUTLIPLAN/IMAGINE 360
MEDCOST
SELF PAY

206 PRINCETON ROAD, STE 18, JOHNSON CITY, TN 37601

+1-423-631-0024 - TEXT: 423-631-0024
423-631-0047 - FAX
crestpp@protonmail.com
OFFICE HOURS Mon: 8am to 4:00pm Tuesday: 8am to 4:00pm Wednesday: TMS/SPRAVATO ONLY Thursday: 8am to 4:00pm Friday: 8am to 12noon

TMS MAGNETIC THERAPY FOR DEPRESSION, OCD, ANXIETY NOW AVAILIABLE

Intake form

Answer each question below

Physician

Services

Neurocognitive Testing

Medication Management

TMS Treatment

ESKETAMINE Treatment

F.A.Q

What should I expect from my first session with the Psychiatrist?

Can I bring a friend or family member for support?

What if I don’t like the Psychiatrist or agree with the recommendations?

Tms intake section

Transcranial magnetic stimulation(TMS)

TMS Patient testimonial

ESketamine (INTRANASAL)

in-network INSURANCE

OFFICE LOCATION