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
Name*
Address*
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?*