Medical Forms

In order to be a patient at Portland Ketamine Clinic you must have a referral from a psychiatrist. We can NOT accept referrals from ANY other mental health care providers incl. MHNP, therapists or psychologists.  Patients will also be required to have monthly referrals from their psychiatrist.
Below is a link to a blank referral form as a PDF.

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

Ketamine Treatment for Chronic Pain Syndrome

Would you like more information?

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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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