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Referral: Esketamine Treatment at GoodMind Sutherland

This form is for clinicians referring a patient for assessment for esketamine treatment at Good Mind Sutherland.

Referring clinician

Referrer name

*

Profession / occupation

*

Referrer email address

*

Patient

Patient first name

*

Patient last name

*

Patient email address

*

Patient mobile number

*

Patient occupation

*

Note if they are former or current police, military or other frontline service?

Clinical indication

Has the patient had an inadequate response to at least two adequate trials of antidepressant medication?

*

A

Yes

B

No

C

Unsure

Treatment-resistant depression is generally defined by an inadequate response to at least two adequate trials of antidepressant medication.

Previous antidepressants

*

At least two previous antidepressants are required.

Is PTSD part of the patient's current clinical presentation?

*

A

Yes

B

No

C

Unsure

Brief clinical comments / reason for referral

*

Funding

How is treatment expected to be funded?

*

A

Self-funded

B

Workers compensation / insurer-funded

C

DVA-funded

D

Unsure

Submission of this referral does not confirm suitability for esketamine treatment. The patient will be assessed by the Good Mind Sutherland team to determine clinical suitability and treatment arrangements.