Spravato Intake Form

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How are you reaching out today?* This field is required.

I’m a patient looking for Spravato treatment

I’m referring a patient for Spravato treatment

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Referrer Name* This field is required.

Full name

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Referrer Role* This field is required.

Healthcare Provider

Employer

Court / Justice Representative

Family / Friend / Other

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Referrer Organization * This field is required.

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Referrer Phone* This field is required.

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Patient Full Name* This field is required.

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Patient Phone Number* This field is required.By providing a telephone number and submitting the form, you are consenting to be contacted by SMS text message and agreeing to our HIPAA Notice of Privacy Practices. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information.

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Patient Email* This field is required.

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Patient Preferred Method of Contact* This field is required.

Call

Text

Email

Other

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Which state does the individual seeking Spravato treatment live in?* This field is required.

Alabama

Mississippi

Tennessee

Other

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Preferred Pathway service location?* This field is required.

Columbus, MS

Birmingham, AL

Jackson, MS

Huntsville, AL

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Is there anything you'd like us to know before we reach out?* This field is required.Please share any relevant details (symptoms, concerns, recent events, discharge plans, court requirements, etc.)

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How did you hear about us?* This field is required.

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Before You Submit!SPRAVATO® (esketamine) is a prescription treatment administered in a certified healthcare setting for certain adults with major depressive disorder (MDD). Our SPRAVATO treatment program is medical care and is not a paid clinical trial or research study. If you are contacting us about SPRAVATO for treatment-resistant depression, this treatment is generally considered for individuals who have been diagnosed with MDD and have tried oral antidepressant medications without adequate relief. Submitting this form does not guarantee that SPRAVATO is appropriate for you or that you will qualify for treatment. Eligibility is determined through a clinical evaluation and may also depend on your medical history and insurance or coverage requirements. Before proceeding, please select "YES" stating that you understand.

YES

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Source Form (internal)

Spravato Intake Form

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Service (internal)

SPRAVATO ®

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Referral Type referral (internal)

Referral Lead

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Referral Type new patient (internal)

New Patient Lead