Therapeutic Infusions — Spravato & Ketamine Patient Referral Form

Therapeutic Infusions — Spravato & Ketamine Patient Referral Form

Quick referral for Spravato/ketamine therapy. Only a few fields are required.
Referring Provider Name

First NameMiddle NameLast Name
Title
Provider Phone
Please enter a valid phone number.Format: (000) 000-0000.
Provider Email
example@example.com
Will you continue to provide psychiatric medication management during the treatment course?
Do you endorce your patient starting Spravato treatment
Patient Full Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Referral Diagnosis
Has the member had an inadequate response to at least two different antidepressants from at least two different classes (different mechanisms of action), during the current depressive episode OR evidenced based psychotherapy (CBT/IPT?
Upload Supporting Documents (recent notes, med list, labs)

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