Psychiatric Referral Form Psychiatric Referral "*" indicates required fields Please note: In order to be a patient at Portland Ketamine Clinic you must have a referral from a Psychiatrist. We can NOT accept referrals from ANY other mental health care providers incl. MHNP, therapists or psychologists.Patient's Name* First Last Patient's Phone Number* Date* MM slash DD slash YYYY Patient's Date of Birth Time in Treatment* Reason for Referral* Current / Previous Diagnosis* Current Medications* Previous Failed Treatments / Medications* NotesReferring Physician's Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Dr. First Last Physician's Phone*Physician's Email* Signature*Please attached your offices notes for the patients last visit Drop files here or Select files Max. file size: 512 MB. CAPTCHAThank you for your referral of this patient. We look forward to collaborating with you to improve their health and well being.Best regards,Portland Ketamine Clinic StaffEmailThis field is for validation purposes and should be left unchanged. website built by Big Screen Advertising