Referral for Treatment

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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's Name*
MM slash DD slash YYYY
Referring Physician's Name*
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    Thank you for your referral of this patient. We look forward to collaborating with you to improve their health and well being.

    Best regards,

    Portland Ketamine Clinic Staff
    This field is for validation purposes and should be left unchanged.