Forms

Medical Forms

To become a patient at our clinic we will need a referral completed by your current psychiatrist and a copy of your last visit clinic notes.  This must be an MD or a DO physician.  We can NOT accept referrals from ANY other mental health care providers incl. MHNP, therapists or psychologists.
We will require that the referral be renewed on a monthly basis by your psychiatrist.
Below is a link to a blank referral form as a PDF.

Psychiatrist / Pain Specialist

If you need a psychiatrist please see the list below.

Portland Area Psychiatrists

Ready to become a new patient? Fill out this easy and secure form!

Medical Intake Form

Authorization to Release Medical Information Form

Psychiatric Referral Form

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Ketamine Treatment for Chronic Pain Syndrome

Would you like more information?

Contact us

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We have chosen to err on the side of safety by using more stringent exclusion guidelines than our purposes require when deemed necessary.  We reserve the right to refuse treatment based on our clinical impression.

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