Spravato Pre-Screening Form
Name
*
First Name
Last Name
Date of Birth
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Please check the appropriate box next to each question.
1. Currently treated for depression?
*
Yes
No
2. Diagnosis (if known)
*
Major Depressive Disorder
Treatment resistant depression
Other
3. Tried at least two different antidepressants in with no or poor response?
*
Yes
No
4. Currently taking an antidepressant?
*
Yes
No
5. Currently seeing a provider for mental health?
*
Yes
No
6. Seen at our clinic before?
*
Yes
No
7. Able to authorize records release if needed?
*
Yes
No
Safety Screening
1. Suicidal thoughts/feels unsafe right now?
*
Yes
No
2. History of stroke/brain aneurysms/brain bleed/condition where BP increase is dangerous?
*
Yes
No
3. Pregnant/trying/ or breastfeeding?
*
Yes
No
4. Substance use concerns within the last 6 months?
*
Yes
No
Spravato Requirements
1. Able to stay in clinic for 2 hour monitoring each visit?
*
Yes
No
2. Have a driver for every treatment visit (can not drive after)?
*
Yes
No
3. Able to commit to induction phase (2x a week for 4 weeks then 1x week for 4 weeks)
*
Yes
No
Insurance/Payment
1. Insurance?
*
Yes
No
Plan Name:
Member ID:
1. Primary Insurance?
*
Yes
No
Thank you for completing the following. Upon review a staff member will reach out with the next steps.
If you have any questions or concerns please call us at 903-213-9120 or email us at info@resolute.sprucecare.com
Submit
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