A TMS consultation is a psychiatric evaluation focused on one question: is TMS a safe and sensible next step for you? Expect a detailed review of your depression and past treatments, standard rating questionnaires, a safety screen for metal, implants and seizure risk, a discussion of the different TMS protocols, and a plan for insurance and scheduling. No magnetic stimulation happens at this visit; that starts at the first treatment session.
The single most useful thing you can bring is an accurate medication history. The rest of this page explains why, and what else to have ready.
What to bring
- Your medication history: every antidepressant and add-on medicine you have taken for depression, with dose, start and stop dates, and why you stopped. The table below shows a simple format.
- Current medications and supplements, including over-the-counter sleep aids and anything you take only sometimes.
- Therapy history: type of therapy, roughly when, and for how long.
- A list of implants or devices: anything in your head, neck or chest, including stents, clips, shunts, cochlear implants, stimulators, pacemakers and defibrillators.
- Relevant medical records: past psychiatric evaluations, hospital discharge summaries, recent blood work, and any brain imaging or EEG reports.
- Insurance card and, if you have it, your plan's behavioral health phone number.
- Your schedule: the hours you could realistically come in each weekday.
- A support person, if you like. They often remember details you forget.
The TMS preparation checklist covers what comes later, before your first session.
Step 1: Your story
The psychiatrist will start with the depression itself: when this episode began, how it affects sleep, appetite, energy, concentration and work, whether you have had earlier episodes, and what has helped before. Expect questions about anxiety, trauma, substance use, family history and physical health, because each one can change the plan.
They will also ask about any history of mania or hypomania and about psychotic symptoms. That is not a formality. Expert consensus says people with psychotic symptoms or acute suicidal thoughts should be considered for other treatments with established efficacy, such as ECT, rather than starting with TMS. Answer openly; it is how the team keeps you safe.
If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.
Step 2: Your medication history, in detail
This part takes the longest, for two reasons. Clinically, the psychiatrist needs to know whether past medicines were given a fair trial, at an adequate dose for long enough, before calling the depression treatment-resistant. Early TMS labeling spelled this out, describing patients who had not improved on an antidepressant "at or above the minimal effective dose and duration." For insurance, the details become evidence. Medicare in Brooklyn, for example, looks for a trial of medicines from at least two different drug classes in the current episode without a clinically significant response, or intolerance shown by two trials from two classes.
A simple table like this is ideal:
| Medicine | Highest dose | Start and stop (approximate) | Result | Why stopped |
|---|---|---|---|---|
| Example: sertraline | Your dose | Month and year | Partial help, no help, or worse | Not enough benefit, side effects, cost |
| Example: an add-on medicine | Your dose | Month and year | Your result | Your reason |
Pharmacy records, patient portals and old prescriber letters can fill gaps. If side effects ended a trial, say exactly what happened; intolerance counts as a reason to consider TMS. See how many antidepressants before TMS is covered and TMS after antidepressant side effects.
Step 3: Therapy history
Some payers require a psychotherapy trial first. Medicare's local policy requires a trial of evidence-based psychotherapy without significant improvement. Be ready to describe what kind of therapy you had (for example CBT or interpersonal therapy), roughly when and for how long. If you could not access therapy, say so; the psychiatrist can note it and may suggest adding therapy alongside TMS. TMS and talk therapy together explains why many people do both.
Step 4: Rating scales
You will likely fill in one or more questionnaires, such as the PHQ-9, and the clinician may rate you on a scale like the HAM-D or MADRS. These give a baseline number so that progress can be measured during the course instead of guessed at, and insurers ask for one: Optum requires a documented baseline score, and Cigna requires scales at the beginning and end of each course. They take a few minutes. Answer for how you have actually felt over the period the form asks about, not for your best or worst day. Tracking your progress during TMS explains what the scores mean.
Step 5: Safety screening
Expect a structured checklist. The main questions are about metal and electronics, because FDA guidance contraindicates TMS with conductive or magnetic-sensitive metal implanted in the head or within 30 cm of the coil, and with implants such as deep brain stimulators, cochlear implants and vagus nerve stimulators. Pacemakers and defibrillators carry a separate labeled warning.
The second group of questions is about seizure risk: past seizures, head injury, stroke and other neurologic conditions. The team will also ask about alcohol, recreational stimulants and sleep, since alcohol withdrawal, cocaine or MDMA use and sleep deprivation can all lower seizure threshold. International safety guidance recommends documenting all current medications, even though it no longer supports its earlier advice of special caution with medicines that lower seizure threshold; the FDA's 2011 guidance still asks for close monitoring with such medicines. Medications during TMS and implants and dental work explain the details.
Step 6: Talking through protocols
There is more than one way to deliver TMS, and a good consultation explains the options and why one is suggested for you. The main families are:
| Protocol | Session length | Typical schedule |
|---|---|---|
| Standard 10 Hz (figure-8 coil) | About 19 to 37.5 minutes, depending on settings | Weekdays for about 6 weeks, sometimes with a taper |
| Theta-burst (iTBS) | About 3 minutes of stimulation | Weekdays for 4 to 6 weeks in the THREE-D trial |
| Deep TMS (H-coil) | About 20 minutes of stimulation in the pivotal trial | 20 sessions over 4 weeks, then twice weekly for 12 weeks in that trial |
| Accelerated protocols | Several sessions per day | Fewer treatment days; FDA-cleared on some systems |
Which options are available depends on the clinic's equipment and your insurance. Good questions to ask are why this protocol, what the evidence for it is, and what happens if you are not improving partway through. The physician's guide to accelerated TMS covers the newer schedules. NICE guidance asks clinicians to tell patients about other treatment options and to make sure they understand TMS may not help them, so expect that conversation too.
Possible outcomes of the visit
A consultation does not always end with "let's start TMS", and that is a sign of a careful evaluation, not a failed one. The common outcomes are:
- Go ahead. TMS fits, and the team starts the insurance and scheduling steps.
- Not yet. A medicine was never given a full trial, a medical cause has not been ruled out, or alcohol or sleep problems need attention first. The psychiatrist suggests those steps and a time to revisit.
- A different treatment first. For psychotic depression or acute suicidal thoughts, consensus points toward treatments such as ECT. Outside emergencies, the Canadian CANMAT guideline says rTMS should generally be considered before ECT because it is less invasive. Other options, such as esketamine, are compared in TMS vs ketamine therapy.
- More information needed. Records from a past prescriber, a medical clearance for an implant, or a neurology opinion about a past seizure.
Whatever the outcome, you should leave knowing why, and what the next step is. If you are unsure, it is reasonable to ask for a written summary or to get a second opinion.
A note on nerves and expectations
Many people arrive at a TMS consultation tired of trying things. It is fine to say so. It is also fine to ask blunt questions: how likely is this to help someone like me, what does "response" mean, and what happens if it does not work. A good clinician answers with ranges and uncertainty rather than a single success rate, because results in studies vary widely with the protocol, the scale used and how the study was designed. What if TMS does not work covers the next steps if a course falls short.
Step 7: Insurance and getting started
Many plans require prior authorization before the first session. The team gathers the diagnosis, rating scores, medication and therapy history and a treatment plan, and sends them to your plan. How long that takes depends on the plan and on how complete your records are, which is another reason the medication table matters. TMS prior authorization, step by step explains the process, and does insurance cover TMS covers what plans typically require.
Once approved, the first treatment visit includes mapping and dose-finding, so it runs longer than later sessions. The first TMS session walks through it.
Questions worth asking before you leave
- Do you think TMS is the right next step for me, and what are the alternatives?
- Which protocol do you recommend, and why?
- Who will supervise my treatment, and who do I call if something feels wrong?
- How will you measure progress, and when will we review it?
- What is the likely timeline from today to my first session?
- What will I owe if insurance covers it, and if it does not?
Our older article on what happens during a psychiatric evaluation covers the general format, and the TMS guide has every related topic. To ask about your own situation, start with TMS therapy.
Sources
- Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. Journal of Clinical Psychiatry, 2018. pmc.ncbi.nlm.nih.gov
- 510(k) K083538 - NeuroStar TMS Therapy System Model 1.1. U.S. Food and Drug Administration, 2008. accessdata.fda.gov
- Transcranial Magnetic Stimulation, LCD L33398 (version 40). Centers for Medicare & Medicaid Services, 2026. cms.gov
- The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. Brain Stimulation, 2016. pmc.ncbi.nlm.nih.gov
- Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems. U.S. Food and Drug Administration, 2011. fda.gov
- Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clinical Neurophysiology, 2021. europepmc.org
- K173620 510(k) Summary - MagVita TMS Therapy System w/Theta Burst Stimulation. U.S. Food and Drug Administration, 2018. accessdata.fda.gov
- K231926 510(k) Summary - NeuroStar Advanced Therapy System. U.S. Food and Drug Administration, 2024. accessdata.fda.gov
- Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial. World Psychiatry, 2015. pmc.ncbi.nlm.nih.gov
- K260189 510(k) Summary - MagVenture Accelerated TMS (aTMS) Therapy System. U.S. Food and Drug Administration, 2026. accessdata.fda.gov
- Repetitive transcranial magnetic stimulation for depression (HTG396, formerly IPG542). NICE, 2015. nice.org.uk
- Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults. Canadian Journal of Psychiatry, 2024. pmc.ncbi.nlm.nih.gov
- Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D): a randomised non-inferiority trial. The Lancet, 2018. pubmed.ncbi.nlm.nih.gov
- Transcranial Magnetic Stimulation (Coverage Policy EN0383). Evernorth Health Services (Cigna), 2026. a.static.cigna.com
- Behavioral Clinical Policy: Transcranial Magnetic Stimulation (BH803TMS112025). Optum Behavioral Health Solutions, 2026. providerexpress.com
FAQs
How long does a TMS consultation take?
It varies by clinic. Plan for a full psychiatric evaluation rather than a quick check-in, and ask when you book.
Do I get TMS at the consultation?
No. The consultation decides whether TMS fits and plans it. Mapping and the first treatment happen at a later visit.
Can I do the consultation by video?
Some clinics do part of the evaluation by telehealth, but mapping and treatment happen in person. Ask the clinic how they handle it.
What if I cannot remember my old medication doses?
Ask your pharmacy for a fill history or check your patient portal. Past prescribers can also send records. Approximate dates are still useful.
Should I stop any medicines before the consultation?
No. Do not change medicines on your own. Bring the list and let the psychiatrist advise you.
