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Healthcare Provider TMS and Ketamine Referral Form
This form is exclusively for medical providers seeking a referral for their patients. This form complies with all HIPAA requirements.

Please complete the information below so we may prioritize your patient's care.

If you are not a provider, please call 406-839-2985 or complete our contact form.

Click here to complete.
Referring Providers Name Name*
Referring Providers Email*
example@example.com
Referring Providers Office Phone Number*

Area CodePhone Number
How can we help? Please choose one of the following.

Patient referral.Please send me more brochures about your advanced services. Including IV Ketamine, and Spravato, and TMS.Other
Patient Referral Information
Which you prefer for this patient referral?

Please call me directly to discuss the patient or to provide patient contact details.I'll complete the patient information below for Montana Psychiatry & Brain Health Center to directly contact this patient.
Which or our offices would best serve this patient?

Billings, MontanaBozeman, MontanaNot sure
Patient's Name
Patient's Phone Number
Patient's Email (if available)
example@example.com
Please check all that applies for the desired patient care.

General PsychiatryTMS TherapyIV KetamineSpravato (Esketamine)Not sure, perhaps either TMS, Ketamine IV, or SpravatoOther
What is (are) the current diagnosis?

Clinical Depression, Major Depressive Disorder, MDDBipolar DisorderAnxiety / General Anxiety DisorderPTSD - Post Traumatic Stress DisorderOCD - Obsessive Compulsive DisorderSchizophrenia or Psychosis of some formOther
If available, what insurance coverage does this patient have?

MedicareTricareMedicaidCommercial health insurance (examples Aetna, Blue Cross / Blue Shield, Cigna, United Health Care etc.)Cash PayNot sure
What else would you like to share with us?
Please click the Submit button below so we may

get back to you in a timely manner.
Should be Empty:

Healthcare Provider TMS and Ketamine Referral Form

Patient Referral Information