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ECT Referral Checklist To help determine if ECT is an appropriate for you, please share the following information with our staff: A brief history of present illness & symptoms Specific goals for ECT treatment Past psychiatric/substance abuse history Medical history Allergies Previous medication trials Current medications Mental status exam results Patients assets & strengths Pertinent lab work results Signature of referring psychiatrist To refer a patient, please call 303-666-2004 and send information via fax to 303-395-0470

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