REFERRAL FORM

Please Complete and Submit the Referral Form Below

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Inclusion Criteria for IV Ketamine

● Adult patients 18 years of age and older.
● Patients with documented *Treatment Resistant Depression as defined below, who have current moderate to severe depressive symptoms will be considered for ketamine.
● The current primary diagnosis, as defined by the DSM-5, is Major Depressive Episode (MDD), or Bipolar 1 disorder or bipolar 2 disorder depressive phase. The patient may have another DSM-5 diagnosis, but this diagnosis cannot be the primary condition or focus of treatment.
● Individuals who have suicidal ideation during the current episode of MDE and meet
the above criteria.
● Individuals who have had previous ECT or rTMS and meet the above requirements are
eligible.
● All patients must complete a medical form and be cleared for intravenous
ketamine by the TKC anesthesiologist. The anesthesiologist will review the
completed medical form prior to the first infusion and any identified medical
concerns will be addressed. The patient may be declined from receiving ketamine
treatment based on their medical history.
● All patients must have capacity to sign a written informed consent for treatment.
● Individuals Post Traumatic Stress Disorder (PTSD) or Obsessive-Compulsive Disorder (OCD) will be considered on a case-by-case basis

*Treatment Resistant Depression (TRD):

Treatment resistant depression the patient has failed at least two guideline concordant trials of antidepressant therapy for major depressive disorder or bipolar depression, as recommended in either the CANMAT MDD Guidelines 2016, Florida Medicaid Guidelines 2019, or the CANMAT ISBD Guidelines for BD 2018

Exclusion Criteria for IV Ketamine

● Patients with a primary diagnosis other than MDD or bipolar 1 or 2 diagnosis.
● Patients who are diagnosed with psychosis , even if it is a symptom of an MDE.
● Patients with neurocognitive disorders , including dementias.
● Patients who have traumatic brain injury that is symptomatic.
● Patients who, within the previous three months, meet the DSM-5 criteria for Alcohol Use
Disorder , or other Substance Use Disorder.
● Patients who do not meet the DSM-5 criteria for Substance Use Disorder, but who use illicit
substances, must stop all illicit substances for a minimum period of 1 month prior to the first
infusion at TKC and remain free from substance use during the treatment time.
● Patients who are unable to provide a written informed consent for ketamine treatment.
● Patients who are not able to abide by the pre-treatment and post-treatment clinic protocol
such as: food intake, abstaining from certain medications, unable to remain in the clinic posttreatment for a minimum of 20 minutes or longer for observation, those who insist on driving
immediately post-treatment, and cannot provide TKC with the name and phone number of the
party who will pick them up post-treatment.
● Patients with: uncontrolled hypertension, epilepsy, allergies to ketamine, a previous reaction to
ketamine, Body Mass Index greater than 35, are pregnant or planning to become pregnant
within 12 weeks of treatment completion, hepatic impairment, history of recent heart attack,
vascular disease, or any other medical conditions that may be deemed by the anesthetist as a
contraindication to receiving ketamine.
● Individuals who are symptomatic for infection, or who have had contact with someone with
an acute contagious illness.
● Individuals who are not Canadian residents or do not have a most responsible
physician (MRP) in Canada.
● Individuals who demonstrate verbal, physical or emotional aggression toward TKC staff or
other patients.
Patients who need to miss an appointment, and do not notify the clinic at least 48
hours before, will be charged a $200 cancellation fee.

Please confirm: *

I have read the Inclusion/Exclusion criteria.

Inclusion and Exclusion Criteria Agreement

I confirm that the patient meets all of the above inclusion and exclusion criteria.

I confirm that I am the patient's ongoing MRP. I will continue to be involved in the patient’s care and provide ongoing psychiatric/mental health care before, during and after receiving treatment at TKC.

I will review all notes and recommendations sent by theTKC for this patient.

I understand that TKC is not able to provide ongoing psychiatric care .

I will notify TKC if the patient develops new medical conditions, or undergoes new treatments, including medications, during the time the patient is receiving treatment at TKC.

MRP will be responsible for abnormal lab result

Referral Request

Referring Physician Contact Information

Name: *

Clinic: *

Phone #: *

Fax #: *

Email Address:

CPSO #:

Billing #: *

Patient Information

Name of Patient *

Patient Date of Birth: *

Patient OHIP #: *

Patient Email: *

Patient Phone #: *

What is your patient’s Primary diagnosis (please choose one of the following):

Major Depressive Disorder

Bipolar 2 Disorder, DEPRESSIVE phase

Does your patient have cognitive impairments? (if yes, please specify) *

Does your patient have Dissociative Identity Disorder? (if yes, please specify) *

Does your patient have Personality Disorders? (if yes, please specify) *

Does your patient have Schizophrenia or other Psychotic Disorders? (if yes, please specify) *

Does your patient have Bipolar I Disorder? (if yes, please specify) *

Does your patient have Alcohol Use Disorder or other Substance Use Disorder? (if yes, please specify) *

Does your patient have Anxiety Disorders? (if yes, please specify) *

Does your patient have Attention Deficit Hyperactivity Disorder? (if yes, please specify) *

If you patient has No Secondary diagnosis please state that clearly below. *

Please describe the patient's Current Psychiatric symptoms? *

Current Medical History (please select all that apply):

Cardiac/Cardiovascular disease

Unstable or poorly controlled hypertension

Uncontrolled brady or tachyarrhythmias

Vertigo

Respiratory

Hepatic

Pancreatic

Genitourinary

Renal

Gastrointestinal

Drug or alcohol dependence

Allergies (environmental/medications)

Ventricular shunts

Uncontrolled hyperthyroidism

None

Other

If 'other' (please explain)

Past Medical History (please select all that apply)

Cardiac/Cardiovascular disease

Unstable or poorly controlled hypertension

Uncontrolled brady or tachyarrhythmias

Vertigo

Respiratory

Hepatic

Pancreatic

Genitourinary

Renal

Gastrointestinal

Drug or alcohol dependence

Allergies (environmental/medications)

Ventricular shunts

Uncontrolled hyperthyroidism

None

Other

If 'other' (please explain)

Medications and Treatments

(details MUST be provided or referral will be considered incomplete)

Has the patient had two trials of anti-depressant medication’s during the Current episode of depression as defined by Treatment Resistant Depression? *

Yes

Has the patient had ECT (Electroconvulsive Therapy) ? *

Yes

Has the patient had TMS ( Transcranial magnetic stimulation) ? *

Yes

Current Treatments and Psychiatric Medications (Must Provide Details) *

Must be included: Name of Medication or Treatment, Current Dose and Length of Time/Effectiveness

Past Treatments and Psychiatric Medications (Must Provide Details) *

Must be included: Name of Medication or Treatment, Maximum Dose and Length of Time on Maximum Dose, Reason for Stopping or Side Effects

Current Physical Medications

Must be included: Name of medication and Dose

Physician Name:

Date: