Spravato/Ketamine Therapy Intake Form

Please correct the errors described below.

Section 1: Patient Information

Section 2: Referral and Treatment Goals

Section 3: Medical History

Section 4: Psychiatric History

Section 5: Substance Use

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

Section 6: Current Lifestyle and Functioning

Section 7: Treatment Logistics

Your information will be encrypted.

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