Healthcare Providers

Please use this form to refer a patient that may be a good candidate for one of Be the Change's Ketamine and TMS Treament Programs.

Please fill out the following form.

Patient First Name*

Patient Last Name*

Patient Phone*

Patient Email*

Patient Diagnosis or Concerns*

Depression

Anxiety

PTSD

Other...

Describe Other Concern

Specifically Interested In*

TMS

Ketamine Assisted Psychotherapy

Uncertain, Please Consult

Will you continue to follow this patient for this issue?*

Yes

Please provide any additional information you think may be pertinent in treating the patient.

Initials*

I declare that the info I’ve provided is accurate and complete.

Referring Provider First Name*

Referring Provider Last Name*

Referring Provider Phone*

Referring Provider Email*

Patient Date of Birth*

Month

Day

Year

Type in "CONFIRM"

Please type in the word CONFIRM above, to confirm that, to the best of your professional assessment/knowledge, the above referred individual does not have psychosis or psychotic features, Bipolar I, or current Methamphetamine abuse.

Get Help Now

First Name

Last Name

Phone

Message

To Get Started or Schedule an Appointment

Call: 707.397.9387
or
Email: info@windowshealthclinic.com

Cotati Location:

Windows Health Clinic
7 Page Street, Suite B
Cotati, CA 94931

bottom of page