Request for Spravato Eval

By completing this form, I confirm that I am NOT in an emergency situation, not suicidal and not in a state of danger to myself or others.

If you or someone you know is suicidal, get help immediately via 911 or the nearest emergency room, the Suicide and Crisis Lifeline by calling or texting 988 or the Crisis Text Line by texting “HOME” to 741741.

Please note that requests are NOT monitored after business hours or on weekends.

Spravato is NOT a safe option for you if you have any of the following:

Aneurysmal vascular disease

including in the brain, chest, abdominal aorta, arms and legs

Arteriovenous malformation

abnormal connection between your veins and arteries

History of bleeding in the brain

Are allergic to esketamine, ketamine

OR any of the other ingredients in SPRAVATO® (citric acid monohydrate, edetate disodium, sodium hydroxide)

Blood pressure ever been abnormal

If yes, please document below

NONE

I do not have and have never been diagnosed with any of the above.

Details regarding blood pressure history

Have you struggled with depression and trialed TWO or more antidepressants without relief?

YES NO

Names of the medications you previously trialed:

Have you ever been diagnosed with bipolar disorder?

YES NO

Have you ever experienced a decreased need for sleep for several days in a row with a significant increased in energy?

YES NO

Have you ever experienced auditory or visual hallucinations?

YES NO

Have you ever experienced paranoia?

YES NO

Kindly list ANY mental health diagnoses you have received historically:

Full name

Date of birth

Address

Zip Code

Email address

Phone Number

Preferred date and time

Based on availability. We are closed on nights and weekends.

Kindly inform us who referred you

Additional Comments/Questions

Provide insurance information below. We are not in network with any Medicare policies, Tenncare, Aetna, or Tricare. Please note Spravato coverage varies depending on your insurance plan.

Do you have any form of Medicare, Tenncare, Aetna, or Tricare insurance policy that is primary or secondary?

Yes No

Insurance Company

If you do not have insurance, please type none.

Member ID

Group ID

Insured's name

Date of Birth

Relation to patient

I understand that sending multiple requests, including using multiple methods of contact, will delay the office's ability to get back with me.

Your information will be encrypted.