Counselor Screening Tool

Ketamine Referral Screening

This tool helps you determine whether your client may be a good candidate for ketamine infusion therapy at Mosaic Infusions & Wellness. Walk through a brief guided screening with your client, and at the end the app will generate a ready-to-send referral email with all the relevant clinical details.

⏱ ~5 minutes 🔒 Anonymous, nothing saved 📩 Email-based referral

Important: This screening is a clinical decision-support tool, not a diagnostic instrument. Mosaic's medical team will make the final determination of candidacy. If your client is in immediate danger or experiencing a mental health crisis, please call 988 or go to the nearest emergency room.

Mosaic Infusions & Wellness
8324 Professional Hill Dr., Fairfax, VA 22031 · (703) 261-4493

Referral Details Step 1 of 2

Your Information

We'll include your contact details in the referral so Mosaic can coordinate care with you.

Your Full Name *

Please enter your name

Credentials *

Please select your credentials

Practice Name *

Please enter your practice name

Email *

Please enter a valid email

Phone *

Please enter your phone number

🔒 Privacy note

Your information is only used to populate the referral email draft. Nothing is saved or transmitted — the email opens in your mail client for you to review before sending.

Referral Details Step 2 of 2

Client Information

Basic demographics for the referral. Use first name and last initial for privacy — you can add the full name before sending.

First Name *

Please enter client's first name

Last Initial *

Please enter last initial

Full Last Name (optional — can add before sending referral)

Age *

Please enter client's age

Sex *

Please select an option

Client Phone (phone and/or email required)

Please provide at least a phone or email

Client Email (phone and/or email required)

Please provide at least a phone or email

🔒 Privacy note

Client information is only used to populate the referral email draft. Nothing is saved or transmitted — the email opens in your mail client for review before sending.

⚠️

Client Safety Takes Priority

Your client's response indicates active suicidal ideation with plan, intent, or access to means. Ketamine referral is not appropriate at this time. Please prioritize immediate safety resources.

📞 988 Suicide & Crisis Lifeline 💬 Text HOME to 741741 Crisis Text Line

🏥 Nearest Emergency Room If in immediate danger

Once the client is stabilized and no longer in acute crisis, you may restart the screening to assess candidacy for ketamine therapy.

Screening Complete Results

Send Referral Final Step

Ready to Send

Your referral is prepared. You can review and edit before sending.

Optionally send your client an intro to Mosaic:

🔒 HIPAA Reminder

Please send from a HIPAA-compliant email account (your practice email). The referral contains clinical screening data — review before sending.