Psychiatric Referral | Portland Ketamine Clinic

Referral for Treatment

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*
First Last
Patient's Phone Number*
Date*
MM slash DD slash YYYY
Patient's Date of Birth
Time in Treatment*
Reason for Referral*
Current / Previous Diagnosis*
Current Medications*
Previous Failed Treatments / Medications*
Untitled
Notes*
Referring Physician's Name*
Dr. First Last
Physician's Phone*
Physician's Email*
Signature*
Please attached your offices notes for the patients last visit
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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
Phone
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