New Patients

Thank you for your interest in Ketamine Infusion Therapy or SPRAVATO (esketamine) nasal spray for Treatment Resistant Depression. Before we can move forward, we need to collect some basic information. Please complete the survey below, all information will be kept confidential. Our staff will review the information and be in touch with you as soon as possible. We look forward to being part of your care.

 

  • Click Here to sign a release for us to submit a benefits investigation for Spravato.

  • Click Here for a Release of information.

Mind Mood Pain New Ketamine or Spravato Intake

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New Patients

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • *If you are having thoughts of harming yourself, please call 911 or go to the nearest emergency immediately.
  • Date Format: MM slash DD slash YYYY
  • Please list the name/dose/frequency/reason.
  • Please list the Name / Dose & Frequency / Start Date / Stop Date / Reason for Discontinuation
  • Have you ever been diagnosed with the following?
  • Date Format: MM slash DD slash YYYY
  • Have you used any of the following substances in the last 6 months? If yes, please list how often you use them and the last date of use. (Please indicate if the substance is medically prescribed)
  • Beck Depression Inventory
  • This field is for validation purposes and should be left unchanged.