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Meet The Providers
Sara Berry, LISW
Katie Ferring, LMSW
Rachel Headings, ARNP
Lacy Orcutt, LMFT
Andi Murray, tLMFT
Jenna Schlegel-Preheim
Holly Sanger, PsyD
Lauren Welter, PhD
Scheduling
Privacy Policy
Contact
FAQ
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PATIENT AND CLINIC INFORMATION
Patient Name:
*
Date of Birth:
*
Age:
Phone Number:
*
Patient Email:
*
Allergies:
Select the one that applies to you
Primary Care Provider
Mental Health Provider
Primary Care/ Mental Health Provider Address:
Provider Email:
Phone Number:
Fax Number:
Mental Health Provider's Clinical Email Address:
THERAPY OPTIONS
Check all that apply
Spravato™ (esketamine) Therapy for Treatment Resistant Depression (Intranasal Route)
Ketamine Assisted Psychotherapy (KAP) with a certified provider (LMFT or PMHNP)
Major depressive disorder, single episode, mild (F32.0)
Major depressive disorder, single episode, moderate (F32.1)
Major depressive disorder, single episode, without psychotic features (F32.2)
Major depressive disorder, single episode, unspecified (F32.9)
Major depressive disorder, recurrent, mild (F33.0)
Major depressive disorder, recurrent, moderate (F33.1)
Major depressive disorder, recurrent, severe without psychotic features (F33.2)
Major depressive disorder recurrent, unspecified (F33.9)
Other diagnosis:
PATIENT DEPRESSION HISTORY
Duration of Current Symptoms:
Suicidal Ideations Present?
Yes
No
Has the patient attempted suicide in the past?
Yes
No
Is the patient currently taking anti-depressants?
Yes
No
Have the medications been effective in reducing depression symptoms?
Yes
No
Current antidepressant medications, dosages, and start date of therapy:
If the patient is not currently taking any anti-depressants, have they taken them before?
Yes
No
Please list previous medications, dates of usage, start/stop dates which were ineffective for treatment of depression:
Other notes about the patient's history of depression:
Referring Provider Name and Title:
Signature:
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Date:
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