Michigan Progressive Health Referral Form

Referring Provider's Name(Required)

First Last

Referring Provider's Email(Required)

Enter Email Confirm Email

Patient's Name(Required)

First Last

Patient's Date of Birth(Required)

Patient's Email

Enter Email Confirm Email

Patient's Phone Number(Required)

Reason for Referral/Relevant Diagnosis(Required)

I am referring the patient for the following service(s)(Required)

IV Ketamine Treatment

Ketamine Assisted Psychotherapy (individual)

Group Ketamine Assisted Psychotherapy

Spravato Treatment

Preferred MPH Location(Required)

Royal Oak

Ann Arbor

Additional Notes or Recommendations (We would appreciate diagnosis and past treatments tried for prospective Spravato patients)

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