Ketamine & Spravato® Consultation Requests

Patients and referring professionals may use this page to request a callback about interventional psychiatric services at Amazing Grace Center.

Please do not submit medical or sensitive information through this form. Do not include diagnoses, symptoms, medications, treatment history, substance-use information, insurance details, medical records, or other patient information. Our team will contact you to complete any appropriate screening or referral steps through an approved process.

Patient Consultation Request

Your request has been received.

Thank you. Please select the best available time for our team to contact you. Do not enter medical details in the appointment scheduler.

Learn more about Ketamine and Spravato® services →

Something went wrong. Please try again or call 740-876-8449.

Contact Information

First Name * Phone Number * Email Address Preferred Contact Method * Best Time to Contact You Preferred Consultation Format * I confirm that I am at least 18 years old. I understand this is only a callback request. I have not included medical, insurance, medication, diagnosis, treatment, or other sensitive information. I authorize Amazing Grace Center to contact me using the method selected above.

This form is not for emergencies, urgent clinical concerns, medication questions, or sharing medical records. For immediate danger, call 911 or go to the nearest emergency department.

Provider Consultation Request

Your request has been received.

Thank you. Please select the best available time for our team to contact you. Do not enter patient information in the appointment scheduler.

Learn more about Ketamine and Spravato® services →

Something went wrong. Please try again or call 740-876-8449.

Professional Contact Information

Provider or Staff Name * Organization or Clinic * Professional Role Direct Phone Number * Work Email * Preferred Contact Method * Best Time to Contact You Preferred Consultation Format * I confirm that I have not entered a patient’s name, date of birth, contact information, diagnosis, medication, treatment history, insurance information, medical record, or any other patient-identifying information. I authorize Amazing Grace Center to contact me regarding its consultation and referral process.

Do not use this form to submit a patient referral or medical records. Our team will provide instructions for securely completing the referral process.

Take the Next Step

Getting started with ketamine treatment should feel easy. Amazing Grace Center offers simple referral options for patients and providers to connect with our team and begin the evaluation process.

Ketamine & Spravato® Consultation Requests

Patient Consultation Request

Your request has been received.

Contact Information

Provider Consultation Request

Your request has been received.

Professional Contact Information

Take the Next Step

We treat the addiction. You reclaim your life.