SPRAVATO INVESTIGATION FORM

Spravato Investigation Form
Patient Name
Date of Birth

Month Day Year
Date
Phone Number
Address
City
State
ZIP
Is the practice authorized to leave detailed voicemails on the number provided above?

Yes No
Employer
Gender Identity

Male/Man Female/Woman Trans Male/Trans Man Trans Female/Trans Woman Gender Queer/Gender Non-Conforming Something Else Decline to Answer Other
Sexual Orientation

Straight Gay Lesbian Bisexual Queer Other Decline to Answer
Significant Other Status

Single Married Partnered Divorced Widowed
Referring Psychiatrist/Psychiatric Nurse Practitioner
Billing address (if different from above)

Same as above
Address

Street Address Line 2
City
State
ZIP
Insurance #1
Effective Date

Month Day Year
Date
Policy #
Group
Policy Holder
Relationship to Patient
Holder DOB

Month Day Year
Insurance #2
Effective Date

Month Day Year
Date
Policy #
Group
Policy Holder
Relationship to Patient
Holder DOB

Month Day Year
Pharmacy Insurance Information
Contract #
BIN
PCN
Should be Empty:

Spravato Investigation Form