Ketamine & Spravato® Referral Forms

Please select the form that best fits your needs. Amazing Grace Center offers interventional psychiatric services including ketamine treatment and Spravato® (esketamine) evaluations for eligible patients.

Select a Form

Self Referral for Ketamine Treatment

Patient Information

Mental Health History

Substance Use

Medical History

Treatment Understanding

Contact Preferences

NOTE: YOUR INFORMATION AND SUBMISSION REMAINS CONFIDENTIAL. WE WILL NOT DISTRIBUTE OR SHARE ANY OF YOUR INFORMATION WITHOUT YOUR EXPRESSED WRITTEN CONSENT.

Provider Referral for Ketamine Treatment

Referring Provider Information

Patient Information

Clinical Information

Medical History

Treatment Preference

NOTE: YOUR INFORMATION AND SUBMISSION REMAINS CONFIDENTIAL. WE WILL NOT DISTRIBUTE OR SHARE ANY OF YOUR INFORMATION WITHOUT YOUR EXPRESSED WRITTEN CONSENT.

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.

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