Treatment Referral Form

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

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/Psychedelic-Assisted Therapy/Other)

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 and any potential contraindications, along with preferred clinic location

rTMS

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

Bedford, NS

Sydney, NS

Fredericton, NB

St. John's, NL

Calgary, AB

Edmonton, AB

Please describe any of the conditions checked off above

Referring Clinician Contact Information

Add another emergency contact

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