Spravato Assessment - Is Spravato Therapy right for me?
How soon are you looking to take care of your depression?
As soon as possible
This week
This month
Within the next 3 months
Have you ever been diagnosed with Major Depressive Disorder (MDD)?
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Yes
No
Have you been diagnosed with Treatment-Resistant Depression?
*
Yes
No
Have you had suicidal thoughts in the past year?
*
Yes
No
How many antidepressant medications have you tried?
*
0-1
2-4
4 or more
Have you ever been diagnosed with Bipolar, Schizophrenia, or other psychotic illnesses?
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Yes, Bipolar
Yes, Schizophrenia
Yes, other
Yes, but I may have been misdiagnosed
No
Have you tried therapy, counseling, or coaching?
Yes, it has helped me
Yes, I have tried with insufficient benefits
Yes, but I stopped going because it wasn't working and/or I didn't like it
No, I have never tried it
Have you heard about Spravato Nasal Spray for Depression?
Yes
No
How did you hear about Spravato Nasal Spray for Depression?
Facebook
Instagram
Evolve Health Website
Google
My Doctor or Health Care Provider
Friend or Family Member
Internet Ad
Other
Who are you taking this survey for?
Myself
Spouse/Partner
Sibling
Parent
Friend
Have you abused any of the following substances in the past 12 months?
Alcohol
Narcotics
Marijuana
Hallucinogens
Prescription Medication
Tobacco / Nicotine
More than one of these
None of these
Do you currently use any other recreational drugs other than Marijuana?
Yes, frequently
Yes, occasionally
No, I used to but I stopped
No, I have never tried any
What is your gender?
Male
Female
Non-binary
Other
Rather not say
Do you have health insurance?
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Yes
No
Which insurance do you have?
*
United Healthcare
Regence
Blue Cross Blue Shield (BCBS)
Aetna
Cigna
Pacific Source
Moda
Kaiser Permanente
Providence
Medicare
Medicaid
OHP
VA
Other
None
What is your age?
Under 18
18-24
25-49
50-64
65 or older
First Name (Press Enter after entering information)
*
Last Name (Press Enter after entering information)
*
Phone (Press Enter after entering information)
*
Email (Press Enter after entering information)
*
Which clinic location is nearest you?
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Beaverton, OR
Portland, OR
Bend, OR
