Referring Provider's Full Name
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Referring Provider's Contact Information
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Client's First Name
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Client's Last Name
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Client's email address
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Client's Phone Number
Has Client tried and failed at least two adequate anti-depressant trials?
Yes
No
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What is Client being referred for?
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Depression, Anxiety, PTSD, OCD, Addiction, PMDD, DMD, etc..
Location
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Location
Sedona
Flagstaff
Prescott Valley
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What service is client being referred for?
TMS (Transcranial Magnetic Stimulation)
Psychiatric Medication Management
IV Ketamine Infusions (Not Covered By Insurance)
Esketamine/Spravato
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