For providers only, If you would like to refer a patient, please fill out and submit the following form.



Reason for Referral: (Check all that Apply)

Current Medications:


Checklist Prior to Referral:

Please Submit Completed Form Online (by clicking the button below) or send a copy of this form to

** Ketamine infusion therapy is one part of your patient’s comprehensive treatment. We require patients to maintain continuity with their referring provider following the completion of their ketamine treatments.