Ketamine Assisted Psychotherapy Referral Form

Ketamine-Assisted Psychotherapy Referral Form
Date*

MonthDayYear
Date
Patient Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Phone*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth

MonthDayYear
Date
Provincial Health Card Number #:*
Does the patient have coverage for Psychotherapy?

YesNo
Gender

MaleFemaleOther
Physician Information
Name*

First NameLast Name
Physician's Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Billing No #*
Physician's Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Specialty*
Physician's E-Mail Address*
example@example.com
Type*

Family PhysicianNurse PractitionerPsychiatristOther Physician
Are you the patient's GP?*

YesNo
If NO, please provide the patient's GP details so the report can be sent to them. GP Name:
Patient’s Primary Diagnosis?
DepressionAnxiety DisorderPost-Traumatic Stress DisorderObsessive Compulsive DisorderAlcohol UsePain
Does the Client have any of the following? (select all that apply)
AddictionsAttention ProblemsEating ProblemsLife Transition/ChangePhobiasRelationship IssuesSkin picking and or Hair pullingWorkplace stressAnger ProblemsCommunication ProblemsGriefObsessions / CompulsionsPhysical Health ProblemsSelf-harmSleep ProblemsAnxietyDepressionHoardingPanicPost-Traumatic StressSuicide AttemptsSocial Anxiety
Please list any other current medical illnesses and medications
Medical History & Medications
Psychiatric Medication History.
Does the patient have the following?*

Poorly controlled hypertensionCAD/CVA/Intracranial bleedAVM/AneurysmsVP shuntPregnancy
Consent:
I agree to manage the follow-up care for the patient?*

Yes
Is the patient aware of and in agreement with this request for service? *

Yes
Does the patient consent to sharing this referral with other health care providers? *

Yes
Has the patient had the following treatments before?*

ECTTMS
Has the patient had any previous psychiatry assessments? If YES, please include these with the referral. *

YesNo
Is the patient under the care of a psychiatrist?*

YesNo
If yes please provide the details of the treating psychiatrist.
Has the patient had any previous psychological assessments? *
If YES, please provide the report if available.

Cancelof
What languages can the patient communicate in?
How did you hear about CMAP Health?
PLEASE SEND ALL PERTINENT CLINICAL SUMMARIES/LAB TESTS/PHYSICAL EXAM FINDINGS

Cancelof
Please note: IF YOU ARE NOT THE PATIENT’S GP AND DO NOT CONSENT TO FOLLOW-UP CARE, THE REFERRAL WILL BE DECLINED
Signature of Referring Physician*

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Date of Referral*

MonthDayYear
Date
Should be Empty:

Ketamine-Assisted Psychotherapy Referral Form

Patient Information

Physician Information

Patient’s Primary Diagnosis?

Does the Client have any of the following? (select all that apply)

Medical History & Medications

Consent: