[Referrer’s contact details]

Subject: Referral to specialized mental healthcare (sGGZ) for rTMS treatment at rTMS International
Date: [To be filled in]

Dear rTMS International practitioner,

Hereby, I, [your name and position], refer patient [patient’s name], born on [date of birth], to your clinic for specialized treatment with rTMS combined with cognitive behavioural therapy. The patient meets the criteria for a depressive disorder with recurrent episodes (DSM code 296.33) and has unfortunately not benefited sufficiently from two previous evidence-based treatment trajectories. Given the treatment resistance, I consider rTMS treatment indicated.

Patient details
Name: [Name]
Date of birth: [Date of birth]
Address: [Address]
Postal code / City: [Postal code] [City]
Citizen service number (BSN): [BSN]
Insurance: [Insurance]

Reason for referral:

1. Complaint or request for help: The patient seeks relief from depressive symptoms.
2. DSM diagnosis: Depressive disorder, recurrent episode (DSM code 296.33).
3. History: The patient has already undergone the following treatments:

• Psychotherapy: [specify type and duration]
• Medication: [specify type and dosage]

Suicidality: [current suicidality status; history: no history/history of suicidality]

Current medication/treatment:
[Medication name], [Dosage], since [Start date]

Allergies/Intolerances:
[Specify if applicable]

If you require further information, I am available at [phone number] or via [email address].

Sincerely,
[Referrer’s name and position]
[Referrer’s AGB code]
[Referrer’s signature and/or practice stamp]