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K. Johns MedicalMedical & Behavioral Health

Patient form · About 5 minutes

SPRAVATO® consultation request

Complete this request to be considered for a SPRAVATO consultation. The office reviews each request and will call you to confirm a consultation appointment. This form does not book an appointment and does not confirm eligibility.

About you

Please give at least a telephone number or an email address so the office can reach you.

How to reach you

The office will call you at the number below to confirm your consultation appointment.

Best way to reach you*
Are you already an established patient of K. Johns Medical?*
Preferred consultation format*
About your treatment history

A brief history helps the clinician prepare. Please keep answers general — a full assessment happens at your consultation.

Have you been diagnosed with treatment-resistant depression or depression with suicidal thoughts?*
Do you have a current prescriber or therapist?*
Have you received SPRAVATO or ketamine treatment before?*
Practical arrangements
SPRAVATO requires monitoring after each dose and you may not drive for the rest of the day. Can you arrange a ride home?*
Acknowledgement

Acknowledgement*

I understand that submitting this request does not book an appointment, does not begin treatment, and does not confirm that I am eligible for SPRAVATO. The office will contact me to confirm a consultation appointment. This website is not monitored in real time. In an emergency I will call 911, or call or text 988 for a mental health or suicide crisis.

Submitting sends your answers directly to K. Johns Medical over an encrypted connection and creates a PDF for your clinician. It does not book an appointment and is not monitored in real time. For an urgent concern, call the office. In an emergency, call 911 or call or text 988.

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