Spravato® Patient Referral form

Please fill out the form below to the best of your ability. If you have any questions or difficulty with completing this form, please feel free to contact us at 914-222-0101

This should take no longer that 2 minutes to complete.

Referring Provider Info:

What is the name and title of referring provider (e.g. John Doe, MD) *

Practice name

Provider Phone Number

Provider Email Address

How would you like us to contact you with Updates on Patient's Care?

Phone

Fax

Health Sharing Portal

Has Patient been advised that Marpa Minds will reach out for a Spravato Evaluation?

Yes

How did you hear about us?

I agree to terms & conditions provided by Marpa Minds. By providing my email and phone number, I agree to receive text and email communications.

Referring Patient Info:

What is your Patient's Name?

What is your Patient's Date of birth

Email address of Patient (if available)

Phone Number of Patient *

Patient Medical History:

A Spravato Referral Form is not Mandatory but helpful in the Coordination of Care

Spravato Referral Form Upload

How long have you been working with the patient?

What is the patient's primary diagnosis for which you are referring them to Marpa Minds

Please provide any other psychiatric/medical information relevant for the referral as applicable

Please list the patient's current medications

Please list the patient's past medication trials

Please provide any comorbid diagnoses that are active and/or relevant (if applicable)

Would you want our provider team to reach out for further collaboration on working with our treatment center? Please list instructions for best communication.