SMC External Referral Form 2026

SPECIALTY MEDICATION CLINIC

REFERRAL FORM
IF THE PATIENT IS EXPERIENCING A MEDICAL OR PSYCHIATRIC EMERGENCY, DO NOT FILL OUT THIS FORM. INSTEAD CALL 911, GO TO THE NEAREST ED, OR CALL 988 FOR ADDITIONAL CRISIS RESOURCES.
Name*

Legal First NameLegal Last Name
DOB*
Previous Names Used
Preferred Name
Social Security #*
Guardian Conservator If Applicable
Mailing Address*
Street Address if different
City*
State*
Zip Code*
*Phone #*
Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact*
May we leave a message with patient information on the preferred phone # above?*

YesNo
INSURANCE INFORMATION
Primary Insurance*
Primary Insured Party Name*
DOB*
Relationship to Patient*
Policy*
Group*
Effective Date*

MonthDayYear
Date
Expiration Date*

MonthDayYear
Date
Secondary Insurance
Primary Insured Party Name
DOB
Relationship to Patient
Policy
Group
Effective Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Insurance Card Images

Cancelof
PRESENTING PROBLEM(S)
Medication being requested: esketamine (intranasal) clinic*

YesNo
Does client meet criteria for treatment resistant depression as defined by CMS? (two medication trials in two categories, during the most recent depressive episode)*

YesNo
Spravato treatment is contraindicated in patients with the following conditions:

Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial, and peripheral arterial vessels) or arteriovenous malformation

History of intracerebral hemorrhage

Hypersensitivity to Esketamine, ketamine, or any of the excipients.
I have discussed this with my patient and they attest that they do not have any of the above stated conditions.*

Yes, the patient indicates NO history of these conditionsNo, the patient indicates a POSITIVE history of a condition listed above. Due to the above condition(s), this referral will be declined. Please discuss this with your patient and do not proceed with this referral.
Contraindication(s):
Does this client have a history of psychosis?*

YesNo
If Yes, please describe condition(s):
Is the client currently taking an oral antidepressant?*

YesNo
If yes, please list medication
Additional information that would be helpful to know about this referral:*
REFERRING PROVIDER INFORMATION
Referred by*
Practice Name*
Email address of referring provider*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date*

MonthDayYear
Date
Clinical File Upload

Cancelof
To fully process this referral, please fax (802)258-3788 or email outpatient@brattlebororetreat.org a copy of:

1) Most recent medical note

2) Medication history

3) Front and back of the individual's insurance card.

Should there be any required information missing, a Practice Management Team member will reach out within 24 business hours to gather the information prior to being able to process the referral.
Should be Empty:

PRESENTING PROBLEM(S)