Dear Colleague,

Thank you for considering a referral to our psychedelic clinic. Kindly review the inclusion and exclusion criteria below before completing the referral.

Inclusion Criteria for IV Psychedelic

Adult patients 18 years of age and older
Patients with diagnosis of Treatment Resistant Depression - defined as failed at least 2 guideline based trials of medication (CANMAT MDD 2016 or CANMAT ISBD 2018)
Current primary diagnosis of Major Depressive Disorder (MDD) or with current major depressive episode due to Bipolar disorder
Patients with a diagnosis of Post Traumatic Stress Disorder
Patients with Anxiety disorders or Obsessive Compulsive Disorders can be considered but will be reviewed on an individual basis
Patients must be capable of consenting to their own treatment

Exclusion Criteria for IV Psychedelic

Active psychosis
Neurocognitive disorders
Alcohol or other substance use disorders - meets DSM5 criteria within the last 3 months
History of verbal or physical aggression
Pregnant or plan to be pregnant within 12 weeks of treatment completion
Prior allergy or severe adverse reaction to psychedelic

I have reviewed the inclusion and exclusion criteria. To the best of my knowledge, my patient meets these criteria. *

Has the patient received psychedelic treatments before?*

Yes No

Patient's Primary Diagnosis*

Most recent Psychiatric Medication trial - 1. Drug name 2. Dose. 3. Length of trial 4. Stop Reason*

Second Psychiatric Medication trial - 1. Drug name 2. Dose. 3. Length of trial 4. Stop Reason*

Medications and Doses

Past Medical History

Cardiac/Valvular disease

Respiratory illness

Liver or pancreatic disease

Neurological disease

Renal disease

Drug or alcohol dependence history

Other

I confirm that I will continue to provide psychiatric care after the course of psychedelic treatment. I understand that Psychedelic Therapy will not provide ongoing psychiatric care. *

I will notify Psychedelic Therapy if I become aware the patient has any change in medical or psychiatric status or undergoes new treatments while they are undergoing treatment with Psychedelic Therapy.*

Referrals

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