Psychiatric Referral Form – Portland Ketamine Clinic Forms

Psychiatric Referral

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

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*

Patient's Date of Birth

Time in Treatment*

Reason for Referral*

Current / Previous Diagnosis*

Current Medications*

Previous Failed Treatments / Medications*

Notes

Referring Physician's Name*

Dr. First Last

Physician's Phone*

Physician's Email*

Signature*

Please attached your offices notes for the patients last visit

Drop files here or

Max. file size: 512 MB.

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Thank 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 Staff

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