Esketamine (Spravato) Clinic

Please download & fill the form and FAX IT TO: 02 6399 2283. if you would like to refer a patient for an assessment for Esketamine treatment.

REFERRAL FOR ESKETAMINE THERAPY

Name

Provider Number

Address

Phone

Fax

Signature

Date

Esketamine treatment is medically supervised but all patients must also have their own Psychiatrist who continues to provide primary care during the course of ketamine treatment.

Title/First name

Last name

DOB

Street Address

Suburb

Postcode

Medicare Number

Ref:

Valid until:

Checkbox

DVA Workcover

Preferred method of contact _{(Complete if your patient consents to our reception team contacting them directly to book an appointment)}

Mobile

Alternative contact_{(Complete if there is someone our reception team can contact if we are unable to reach the patient)}

Name

Relationship

Phone number

Current General Practitioner _{(if known)}

Name

Practice

INDICATION FOR ESKETAMINE _{MUST APPLY FOR REFERRAL TO BE CONSIDERED)}

Treatment resistant depression _{(failure to respond to at least two different antidepressants of adequate dose and duration)}

Additional information _{(attach separate sheet if required)}

Brief clinical summary (please outline a brief history of illness and treatment history including all previous antidepressants trialled, duration and doses if known)

Other psychiatric treatments trialled eg ECT, TMS, ketamine etc

Other psychiatric conditions present

Other medical conditions

Hypertension Known vascular aneurysm (intracranial, abdominal, thoracic, other peripheral arterial) Past history of intracranial Haemorrhage None of the above

Attach separate sheet if required

Esketamine (Spravato) is an approved treatment by the Therapeutic Goods Administration (TGA) for Treatment-Resistant Depression, a condition characterized by ongoing depressive symptoms despite adequate trials of at least two different antidepressant medications.

Spravato, a ketamine-based nasal spray, has demonstrated efficacy and safety in managing severe forms of depression. Given its classification as a controlled medicine, it is administered exclusively at authorised clinics, including Mindsight Clinic. From 1 May 2025, Spravato has been listed on the Pharmaceutical Benefits Scheme (PBS), providing subsidised access to patients who fulfil the required eligibility criteria.

If you believe this treatment may be appropriate for your condition, we encourage you to consult with your treating psychiatrist or general practitioner (GP) for further assessment and guidance.

Please note: Access to esketamine requires a referral from a currently treating psychiatrist. If you are not under the care of a psychiatrist, we recommend discussing your options with your general practitioner (GP), who can assist with the referral process.