Spravato is a depression treatment that can improve response in patients for whom current medication therapies and psychotherapies for major depression have not provided satisfactory results, or individuals who have experienced negative side-effects from medications.

Should you find it helpful, feel free to review the below links regarding the efficacy of Spravato for depression.

General Spravato information
Spravato Therapy for Depression - Review of the Evidence

Patient name (First and Last) *

First Name

Last Name

Patient Phone Number *

Patient birthdate (must be 18 or older) *

YYYY

Patient address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance carrier and policy number *

Referring doctor *

Office's Contact Phone and/or Email *

Does the Patient have a current diagnosis of Major Depression Disorder symptoms? *

Yes

Select one

F33.1

F33.2

Select One

90791

90792

Other

Has Patient been treated with at least two (2) medications? (Please List and/or send Medical Records) *

Include: Names, Dosage, Dates, Duration, Outcome

Has patient tried psychotherapy? *

Yes

Are you aware of any contraindicators? *

Yes

If yes, please list them.

Have you discussed and recommended Spravato as an option with your patient? *

Yes

Other related health concerns (Seizures, Dementia, Stroke, Acute psychosis, Serious Illness, Non-adherence to Tx *

Yes

Additional impressions or comments:

Find a Qualified Mental, Behavioral (ABA), Speech or Psychiatric Medical Provider Located Near You.

The well-being and success of every patient is our top priority.

For over 10 years, we’ve supported families, children, teens & individuals across Northern Utah.
We look forward to helping you and your loved ones achieve their goals.

Bountiful
Autism Services (ABA) , Mental Health,
Speech Therapy & Medical Clinic

415 S. Medical Dr.
Suite A100
Bountiful, UT 84010

Layton
Mental Health Clinic

920 West Heritage Park Blvd.
Suite 210
Layton, UT 84041

Salt Lake City
Mental Health Clinic

370 E South Temple
Suite 175
Salt Lake City, UT 84111

Ogden
Autism Services (ABA) &
Speech Therapy Clinic

5974 S. Fashion Pointe Dr.
Suite 140
South Ogden, UT 84403

West Jordan
Autism Services (ABA) Clinic

7613 S. Jordan Landing Blvd.
Suite 120
West Jordan, UT 84084

Ogden
Mental Health & Medical Clinic

5926 S. Fashion Pointe Dr.
Suite 120
South Ogden, UT 84403

Logan
Autism Services (ABA) Clinic

429 Main Street
Logan, UT 84321

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Spravato Therapy Referral Form

Find a Qualified Mental, Behavioral (ABA), Speech or Psychiatric Medical Provider Located Near You.

For over 10 years, we’ve supported families, children, teens & individuals across Northern Utah. We look forward to helping you and your loved ones achieve their goals.

For over 10 years, we’ve supported families, children, teens & individuals across Northern Utah.
We look forward to helping you and your loved ones achieve their goals.