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
YesNo
PatientRepresentative
Representative's Name*

First NameLast Name
Relation to Patient*
Current Provider & Referral
YesNo
Please list the name of your prescribing provider and practice location*
YesNo
I acknowledge
Medications and History
YesNo
List ALL psychiatric medications currently taking (no doses).*
Example: Lexapro, Lamictal, Seroquel
DepressionBipolar disorderPsychosis or schizophreniaEating disorderBody dysmorphic disorderPersonality disorderPTSDSubstance use disorderNone of the above
Hospitalization & Safety
YesNo
YesNo
YesNo
If Yes, Please contact 988 or nearest emergency room.
Medical Contraindications
Aneurysm or vascular malformationUncontrolled high blood pressureHistory of brain bleed or strokeAllergy to ketamine or esketamineNone of the above
Pregnancy Screening
MaleFemale
YesNo
YesNo
Treatment Commitment
I am able to attend in-office treatment sessions twice per week during the initial phase of treatment (4 weeks).I understand that each treatment visit requires a full 2-hour in-office monitoring period with no exceptions.I understand that I am NOT allowed to drive myself after treatment sessions and must have reliable transportation arranged.
Final Agreement
I understand that if I have a current psychiatric or prescribing provider, they must submit a referral for Spravato treatment, along with a signed Release of Information and my two most recent progress notes, to the office prior to my scheduled Spravato consultation.I understand that a consultation will NOT be scheduled until all required documentation has been received and reviewed by the office.I understand that completing this screening form does NOT guarantee treatment, and that all final treatment decisions are determined by Dr. Horton after clinical review.
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Spravato Treatment Screening – New Patients

Patient Information

Eligibility

Current Provider & Referral

Medications and History

Hospitalization & Safety

Medical Contraindications

Pregnancy Screening

Treatment Commitment

Final Agreement