Intake Form PKC

"*" indicates required fields

Step 1 of 2

Please note: 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.
Patient Intake Form for Portland Ketamine Clinic
Patient Information
MM slash DD slash YYYY
Can NOT be your name
Can NOT be your phone number
Seeking Treatment For:*
If you are not currently on any medication, Please type "NONE."
Are You Currently Taking MAOI Inhibitors?*
Are You Currently Pregnant, Breast Feeding or Plan On Becoming Pregnant in the Near Future?*
Have You Had Thoughts of Suicide?*
Have You Ever Been Hospitalized in an In-Patient Psychiatric Unit?*