Do you have a professional diagnosis?

This form simply acknowledges that you and the patient you name have an ongoing relationship and that he/she is under your care.  Completion of this form does NOT imply recommendation or approval of ketamine infusion therapy.  If you have already completed the Patient Referral Form, you do not need to complete this form.

Ketamine Infusion Pre-Screening & Intake Forms

Prior to beginning your ketamine infusions, it is important for us to understand and evaluate your level of depression and/or anxiety. This helps us identify any other conditions that may complicate your treatments, or render them ineffective.

Please review our Privacy Practices and complete the following forms prior to your first treatment: