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Type into the sheet below, then print it or save it as a PDF and fax the completed sheet to (818) 793-5094. Prefer to talk it through? Call the provider line at (818) 793-5067.

Deep TMS Referral: Breakthrough TMS

Breakthrough TMS, 100 W Broadway #1050, Glendale, CA 91210
Fax completed sheet to (818) 793-5094 · Provider line (818) 793-5067

Referring Provider

Name / Credentials: Practice: Phone: Email: Fax for our reply:

Patient

Name: Date of birth: Phone: Email:

Preferred method of contact: Phone Text Email

Reason for Referral

Major Depressive Disorder (adult) Anxious depression Late-life depression (through age 86) OCD Adolescent MDD (15+) Smoking cessation Off-label

Working diagnosis / notes:

We treat the TMS episode and return your patient to your care with a treatment summary. Our team will contact your office after receiving this referral, and we complete candidacy and safety screening on our end.

Address: 100 W Broadway #1050
Glendale, CA 91210

Phone: (818) 793-5067

Fax: (818) 793-5094

Email: info@tmsbreakthrough.com

Hours: Monday to Friday, 7:00 AM to 7:00 PM

Find Us

Office status: Office hours Mon–Fri · 7:00 AM – 7:00 PM PT

The information on this website is for general educational purposes only and is not medical advice. Breakthrough TMS does not provide emergency services. If you are experiencing a medical emergency or are in immediate danger, call 911. If you or someone you know is in crisis, call or text 988. Use of this website or contacting our office through this website does not create a provider-patient relationship. Treatment eligibility is determined after an in-person evaluation and safety screening. Individual results vary.

Call (818) 793-5067