Spravato/Ketamine Therapy Intake Form

Section 1: Patient Information

First Name

Last Name

Date of Birth

Phone number

Email address

Address

Insurance

Emergency Contact Name

Emergency Contact Number

Section 2: Referral and Treatment Goals

How did you hear from Spravato/Ketamine treatment?

Referred by provider Online search Friend/Family Other:

Please specify:

Are you currently under the care of a psychiatrist or therapist?

Yes No

If YES, please list their name & contact info:

What are your primary goals for seeking treatment with Spravato/Ketamine? (Check all that apply)

Depression

Suicidal Thoughts

Anxiety

PTSD

OCD

Chronic Pain

Others:

Section 3: Medical History

Please list any surgeries or hospitalization (with dates)

Current medications (including psychiatric & over-the-counter):

Allergies (including medications):

Section 4: Psychiatric History

Have you ever been diagnosed with any of the following?

Major depressive disorder

Bipolar disorder

PTSD

Generalized anxiety disorder

Panic disorder

OCD

Schizophrenia or psychosis

Substance use disorder

Personality disorder

Do you currently have or have you ever experienced suicidal thoughts?

Yes No

If YES, are you currently experiencing suicidal thoughts?

Yes No

History of suicide attempts?

Yes No

If yes, how many and when?

Have you previously tried any of the following treatments? (Check all that apply)

Antidepressants (SSRIs, SNRIs, etc.)

Therapy (CBT, DBT, etc.)

TMS (Transcranial Magnetic Stimulation)

ECT (Electroconvulsive Therapy)

Hospitalization for psychiatric reasons

Others:

Section 5: Substance Use

Do you currently or have you ever used any of the following?

Alcohol:

Never Occasionally Frequently

Cannabis:

Never Occasionally Frequently

Opioids::

Never Occasionally Frequently

Benzodiazepines (e.g., Xanax):

Never Occasionally Frequently

Cocaine/methamphetamines:

Never Occasionally Frequently

Hallucinogens (e.g., LSD, psilocybin):

Never Occasionally Frequently

Ketamine (outside medical use):

Never Occasionally Frequently

Please describe:

Section 6: Current Lifestyle and Functioning

Rate your current level of functioning (1 = very poor, 10 = excellent): ___ /10

Do you currently work or attend school?

Yes No

If yes, describe role and schedule:

Do you currently work or attend school?

Yes No

Who is in your support system?

How many hours of sleep do you typically get per night?

Do you use any assistive devices or have mobility issues?

Yes No

If yes, please describe:

Section 7: Treatment Logistics

Are you able to commit to 2 visits per week for the first 4 weeks?

Yes No

Do you have transportation arranged for treatment sessions? (You cannot drive yourself home after Spravato/ketamine treatment.)

Yes No

If YES, who will transport you?

Do you understand that you will be monitored for at least 2 hours post-dose?

Yes No

Your information will be encrypted.