Patient Intake 
EPIC Healing Eugene

Date: 

Name:

Gender/Preferred Identification:

Phone Numbers: (specify cell #)

OK to leave message?  

OK to text cell #?

Address:

Living Situation:

(Alone, married, roommate, supported living, etc.)

Emergency Contact (Name and phone #):

Date of Birth:

Current Age:

(Must be at least 21 for some services; ID required)

          Ketamine Services generally 18 and up.

Occupation:                                                 Retired: 

Other:

Relationship to person filling out intake (e.g., self, parent, spouse, etc.):

Seeking treatment for:

Fill out next section if inquiring about Ketamine Assisted Psychotherapy:

Age:                         Weight                          Height 

Physicians Name:                                    Last time seen?

Physician Address/Contact Information:

If seeing a Medical Specialist, please give contact information and condition being treated:

No Doctor? 

Do you have Cardiac issues? 

Blood pressure issues?  

Blood Pressure issues managed by medications? 

Neurological issues? 

Liver issues? 

Kidney issues? 

Other? 

(Please attach a doctor’s visit narrative or discharge instructions, if available)

Can you arrange transportation on service days, and agree not to drive the day of services?

­­­Will you need assistance with transport? ­­

Current medications/dosage of medications related to help manage mood or other psychological/ neurological symptoms: (Attach List)

What medications/treatments have helped in the past? 

Allergies: 

Are you currently pregnant, planning to become pregnant, or breastfeeding? 

Current/previous psychiatric diagnoses: 

History of Psychosis?

History of unstable mental health condition?

Chronic Insomnia? 

Do you have depression?               How long? 

History of Mania?                   Mood Disorder Diagnosis? 

Anxiety?           How long? 

Trauma History?                  How long? 

History of Substance Abuse or Alcohol Use Problems? 

Current status:

Have you had any thoughts of suicide or suicide attempts? 

If so, when did you last think and/or attempt suicide?

Briefly describe past and current mental health status: 

Please provide the condition and dates if ever admitted to an inpatient psychiatric unit:

Current psychiatrist:                                                Phone:

Current therapist:                                                   Phone:

(Include contact information)

Anything else which you'd like our medical and mental health team to be aware of?

My statements noted above in this initial screening for ketamine services with EPIC Healing Eugene are accurate and is an accurate portrayal of my current and past medical and medical health history.

Signature                                                                  Date

Thank you for filling out this EPIC ketamine services inquiry form. Please note our services are short-term, so if seeking long-term counseling services, please also do this in addition to the short-term services we offer. Having a regular therapist may be required. 

I understand that medical and mental health services with EPIC Healing Eugene are short-term based on ketamine medicine sessions and ketamine assisted psychotherapy services arranged and pre-paid for. Some services may be covered by your insurance, but most are not. If you wish to use your insurance for counseling associated with preparation and integration services, additional paperwork will be required so EPIC’s mental health staff can bill your insurance. By completing this initial inquiry for services does not obligate you or EPIC to engage in services, but does provide the basis for scheduling a consultation, and also for meeting with one of EPIC’s Medical Ketamine Prescribers. 

Our team at EPIC Healing Eugene will review and get back to you via email with updates regarding your request for services, and next steps. Thank you. 

Initials:                                                                         Date:

Warmly, 

     EPIC Healing Eugene