Treatment Resistant Depression Clinic Clinician Referral Form

Treatment Resistant Depression Clinic Clinician Referral Form Patient Date: Name: Contact DOB: Sex: No: Ref. By: Contact: **Treating Contact: Psychiatrist: Primary Please Include Copy of Patient’s Insurance Insurance Card (Front and Back) Provider: PSYCHIATRIC NOTES How long have you known this patient? Current Diagnosis/Diagnoses: Current/Target Symptoms Past History of ECT □NO □YES If YES, # of sessions: Type: □UL □BF □BT Dates: Past response: □excellent □good □fair □poor □unknown Past History of TMS □NO □YES If YES, # of sessions: Dates: Past response: □excellent □good □fair □poor □unknown Current Medications: Current Medical Problems Emory Treatment Resistant Depression Clinic Clinician Referral Form 10/07/15 Allergies Do we have permission to contact the patient? □NO □YES ADDITIONAL NOTES Clinical Impression : Please complete the attached medication history form Include a copy of the patient’s insurance card (front and back) Fax referral form to: 404 712 7436. Attn: Emory TRD Clinic If you have any questions, please contact: Taelar Johnson at 404 712 8732 Emory Treatment Resistant Depression Clinic Clinician Referral Form 10/07/15 Generic Date drug How many weeks drug Drug Class Name was tried Min. Dose Max Dose Dosage was taken? Was it helpful?/Side Effects TCA Adapin Doxepin 150mg/d 250mg/d Anafranil Clomipramine 150mg/d 250mg/d Asendin Amoxapine 150mg/d 250mg/d Endep/Elavil Amitriptyline 150mg/d 250mg/d Ludiomil Maprotiline 150mg/d 250mg/d Norpramin Desipramine 150mg/d 250mg/d Pamelor Nortyrptiline 75mg/d 125mg/d Sinequin Doxepin 150mg/d 250mg/d Surmontil Trimipramine 150mg/d 250mg/d Tofranil Imipramine 150mg/d 250mg/d Vivactil Protryptiline 30mg/d 60mg/d Azafen Pipofezine 150mg/d 300mg/d Agedal/Eltrono Noxiptiline 100mg/d 200mg/d Merival/Alival Nomifensine MAOIs Marplan Isocarboxazid 30mg/d 60mg/d Nardil Phenelzine 45mg/d 90mg/d Parnate Tranylcypromine 30mg/d 60mg/d Emsam Selegiline patch 6mg/24hrs 12mg/24hrs Aurorix Moclobemide 300mg/d 600mg/d Pirazidol Pirlindone 200mg/d 300mg/d SSRI Luvox Fluvoxamine 50mg/d 150mg/d Paxil Paroxetine 50mg/d 150mg/d Prozac Fluoxetine 20/25mg/d 60/75mg/d Zoloft Sertraline 50mg/d 150mg/d Celexa Citalopram 20mg/d 60mg/d Lexapro Escitalopram 10mg/d 30mg/d SNRI Effexor Venlafaxine 150mg/d 250mg/d Cymbalta Duloxetine 60mg/d 120mg/d Pristiq Desvenlafaxine 50mg/d 100mg/d Savella Milnacipram 100mg/d 200mg/d Fetzima Levomilnacipram Other Strattera Atomaxetine 40mg/d 80mg/d Wellbutrin Bupropion 300mg/d 450mg/d Remeron Mirtazapine 15mg/d 45mg/d Serozone Nefazodone 300mg/d 600mg/d Emory Treatment Resistant Depression Clinic Clinician Referral Form 10/07/15 Edronax Reboxatine 4mg/d 8mg/d Stablon Tianeptine 37.5mg/d 75mg/d Vibryd Vilazodone 40mg/d 80mg/d Brintellix Vortioxetine Generic Date drug How many weeks drug Drug Class Name was tried Min. Dose Max Dose Dosage was taken? Was it helpful?/Side Effects Anticonvulsants Lithium Tegretol carbamazepine Depakote Divalproex Neurontin Gabapentin Lamictal Lamotigine Trileptal Oxacarbazepine Depakote valproate Depakene valproic acid Antipsychotics Abilify Aripiprazole Saphris Asenapine Drug Class Clozaril Clozapine Fanapt Iloperidone Latuda Lurasidone Zyprexa Olanzapine Invega Paliperidone Seroquel Quetiapine Risperdal Risperidone Geodon Ziprasidone NDMA Antagonist Ketamine Stimulants Nuvigil Armodafinil Adderal amphetamine Vyvanase Lisdexampheta mine Ritalin Methylphenidat e Provigil Modafinil Sedatives and Sleeping Agents Klonopin Clonazepam Xanax Alprazolam valium Diazepam Benadryl Diphenhydramin e Lunesta Eszopiclone Ativan Lorazepam Serax Oxazepam Restoril Temazepam Trazodone Halicon Triazolam Sonata Zaleplon Emory Treatment Resistant Depression Clinic Clinician Referral Form 10/07/15 Ambien Zolpidem Augmenting Buspar Buspirone Cytomel Lioothyronine Emory Treatment Resistant Depression Clinic Clinician Referral Form 10/07/15 .

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