Treatment Referral Form - Mental Health - This form must be completed by a treating clinician (Physician, NP, Psychologist)

Thank you for referring your patient for treatment at ANSR Clinic

If you have any questions, please do not hesitate to call or email us.

902-466-2677 (Phone)
902-455-2677 (FAX)
info@ansrclinic.com

Client Information

First name

Last name

Contact phone number

Alternate Phone Number

Email address

Date of birth

Address

Health Card # or Veteran ID (K#)

Patients Caretaker Name (if applicable)

What is the Clinical Indication for treatment?

Please check all that apply

Major Depressive Disorder

Bipolar Disorder

Posttraumatic Stress Disorder

Other

If other was checked off, please provide details:

Medical Information

Current Medications and Doses (Indicate 'None' if not taking medications)

Some funders require 2 first line antidepressant trials, current or past, please list any first line antidepressants patient is currently using here

Previous Medication Trials (Indicate 'None' if there are no past medication trials)

Some funders require 2 first line antidepressant trials, current or past, please list any first line antidepressants trialed here

Non-pharmacological Management - Current or Past Trials (ie. Therapy/ECT/rTMS/EDMR/Psychedelic-Assisted Therapy/Other) (Indicate 'None' if there are no past medication trials)

Some funders require patients to have trialed non-pharmacological therapy or treatments for approval of services.

Brief Clinical History (including any known allergies)

If you could please upload any reports, or previous psychiatric assessments you may have, or fax to 902-455-2677. It would be greatly appreciated!

Add file

Please upload a file

Referral Type

Please select the recommended treatment below, and any potential contraindications, along with preferred clinic location

rTMS

Please select the patients preferred treatment location below

Preferred Location

Bedford, NS

Fredericton, NB

St. John's, NL

Calgary, AB

Edmonton, AB

Please describe any of the conditions checked off above

Ketamine Treatment

Please select the patients preferred location, and Tx modality/modalities below

Bedford, NS

IN (Spravato)

Sydney, NS

IN (Spravato)

Fredericton, NB

IN (Spravato)

St. John's, NL

IN (Spravato)

Calgary, AB

IN (Spravato)

Edmonton, AB

IN (Spravato)

Please describe any of the conditions checked off above

Referring Clinician Contact Information

By submitting this information you attest that you are a Physician, Nurse Practitioner or Psychologist and that you agree to use of electronic communication.

Add another physicians contact info

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