Patient information

Which clinic location? *

Portland, OR

Beaverton, OR

Bend, OR

Referral for treatment with: (Please check all that apply) *

Evaluate & Treat

TMS

SPRAVATO® (esketamine) Nasal Spray

Ketamine IV/IM

Request Type *

Standard: Major Depressive Disorder, recurrent moderate to severe

Expedited: Major Depressive Disorder with acute suicidal ideation or behavior

Please call the clinic for expedited referrals.

Clinical Information: Please attach pertinent clinical notes and additional information.

Diagnosis with ICD-10:

Please attach any of the following on file:

Current PHQ-9, HAM-D, QIDS-SR, or MADRS depression scale scores.
Summary of patient’s treatment and/or medication history

Additional Requests or Concerns:

How would you prefer to receive updates on your patient’s progress?

Email

Phone

Fax

Provider Phone Number

Provider Email *

Provider Fax

Referring Organization

Referring Provider Name

Provider Signature:

Clear

File Attachments:

Attach files here

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