Get started

Ten minutes now. Your first treatment, usually within days.

Register below and we take it from there: our team starts your insurance check right away and reaches out, usually within one business day, to schedule your evaluation. Everyone starts with this form, so the sooner it’s in, the sooner you’re seen.

Start my registration

Only the starred fields are required. Save the rest for your evaluation if you’re unsure.

A woman with curly hair sits cross-legged on a gray couch in a bright, plant-filled apartment, typing on a laptop on her knees.

Register for your Spravato evaluation

01About you

First name

Last name

Date of birth

Sex

Marital status

02Contact

Street address

City

State

ZIP code

Mobile phone

Email

03Insurance

No insurance? Choose that and send the form anyway. We help you get Spravato through the manufacturer, and our fee stays $40 a session.

Do you have health insurance?

Yes, I have health insurance No, I’m uninsured right now

04Why you’re reaching out

What’s going on, in your own words?For example: “Depression for 8 years. Tried three antidepressants, only partial relief.”

05Depression and mental health history

Antidepressants you’ve tried beforeNames are enough. Rough is fine; we fill in the rest from your past prescribers.

Antidepressants you take nowWrite “None” if none.

Your depression historyHow long, and what treatment you’ve had.

Psychiatric diagnoses you’ve been given

Other psychiatric medications you’ve triedMood stabilizers, antipsychotics, anti-anxiety or ADHD medications, for example.

Mental health conditions in your familyFor example: “Mother: depression. Brother: bipolar disorder.”

Your other doctors and therapistsNames and towns, if you have them.

06How you’ve been feeling

Over the last two weeks, how often have you been bothered by the following?

07Medical history

Current medications and supplementsInclude dose if you know it, e.g. “Zoloft 100 mg daily.”

AllergiesFor example: “Penicillin: rash.” Leave blank if none.

Medical conditionsFor example: “High blood pressure since 2018.”

SurgeriesWhat, and roughly when.

08Lifestyle

Tobacco

I smoke now I used to, and quit Never

Alcohol in a typical weekFor example: “2 glasses of wine, 3 nights a week.”

Recreational substance useThis helps us keep you safe. Leave blank if none.

09Anything else

Anything else you’d like our team to know?

10Consent and signature

I have reviewed the privacy policy

Electronic signature Type your full legal name. Under the ESIGN Act this is as binding as a handwritten signature, confirms the information above is accurate, and gives your consent to receive care from PremierMD.

11How did you find us?

After you send it

We do the rest.

We call youUsually within one business day, to schedule your evaluation.
Your evaluationUsually a video visit you do from home. A clinician goes through your history with you, and you decide together whether Spravato fits.
Insurance approvalWe do the prior authorization, start to finish. You aren’t asked to chase your insurer.
Your first treatmentUsually two to three days after you first reach us.

Before you send it

Questions people ask first.

Can I register by phone instead?

Everyone registers with this form. It’s how your history reaches the clinician who evaluates you, and what we send your insurer for approval. If a question stumps you, leave it blank or call (908) 450-7002 and we’ll help you through it.

Do I have to come in for the evaluation?

Usually not. Almost every evaluation is a video visit you do from home. You come to one of our offices for the treatments themselves, which have to be given in a certified office.

Do I need a referral?

No. You can register directly. If you have a psychiatrist or therapist, we’ll coordinate with them, but you don’t need their referral to start.

What if I’m not sure Spravato is right for me?

Register anyway. The evaluation is where we work that out with you, and if Spravato isn’t the right fit we’ll tell you plainly.

What will it cost?

Patients typically pay $0 with NJ Medicaid, or up to $40 a treatment with commercial insurance after the manufacturer’s SpravatoWithMe program. No insurance, or a plan that genuinely won’t cover it? We help you get Spravato through the manufacturer, and our fee is $40 a session. We confirm your exact cost before you commit.

Why do you ask so many questions?

So your evaluation can start where your history leaves off, and so we can begin your insurance approval, which needs your diagnosis and the antidepressants you’ve tried. Only the starred fields are required.

How is my information used?

Only to prepare for your evaluation and to check your insurance. It’s sent over an encrypted connection to our patient registration system and seen only by our clinical and intake team.