Patient Name
*
First Name
Last Name
Patient Date of Birth
*
/
Month
/
Day
Year
Patient Cell
*
Please enter a valid phone number.
Patient Email
*
example@example.com
{patientName} is being referred for evaluation prior to initiating Ketamine Assisted Psychotherapy.
Treatment Protocol
*
Depression
Trauma
Has the patient been thoroughly counseled on the potential sedative and dissociative effects associated with treatment using ketamine?
*
Yes
No
Anticipated date of first KAP session
*
-
Month
-
Day
Year
Date
Counseling Provided by:
*
Please enter provider name and credentials.
Referred by:
*
Please enter provider name and credentials.
Optional file upload (Demographics, etc)
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