Spravato Treatment Screening

Spravato Treatment Screening – New Patients
This is a preliminary screening for Spravato treatment. Completion does not guarantee eligibility. All submissions are reviewed by Dr. Horton. Consultation required if approved. This form will take approx 10 min to complete.
Patient Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Eligibility
Are you 18 or older? ( You must be over 18 to receive Spravato Treatment)
Who is completing this form?
Representative's Name

First NameLast Name
Relation to Patient
Current Provider & Referral
Do you have a psychiatrist or prescribing provider?
Please list the name of your prescribing provider and practice location
Referred for Spravato treatment by your provider?
If you have a current provider, referral and records are required before scheduling.
Medications and History
Are you currently taking psychiatric medications?
List ALL psychiatric medications currently taking (no doses).
Example: Lexapro, Lamictal, Seroquel
Mental Health History
Hospitalization & Safety
Ever hospitalized for mental health reasons?
Hospitalized within past 30 days?
Currently experiencing thoughts of self-harm?
If Yes, Please contact 988 or nearest emergency room.
Medical Contraindications
Medical Contraindications (Please list all that apply)
Pregnancy Screening
Sex assigned at birth
Possibility of pregnancy?
Willing to complete pregnancy test if required?
Treatment Commitment
Treatment Commitment
Final Agreement
Final Agreement
Should be Empty:

Spravato Treatment Screening – New Patients

Patient Information

Eligibility

Current Provider & Referral

Medications and History

Hospitalization & Safety

Medical Contraindications

Pregnancy Screening

Treatment Commitment

Final Agreement