FOR REFERRING PHYSICIANS

Is Psychedelic-Assisted Therapy Right for Your Patient?

Bloom Institute offers physician-supervised, psychiatrist-guided psychedelic-assisted therapy for adults with treatment-resistant mental health conditions. Initial intake assessments are covered by Alberta Health Services.

PAT Clinician Referral Form

Download, complete, and fax to (403) 948-3353.

Incomplete referral forms will not be accepted and will be returned to sender.
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Appropriate if the patient:

  • Has MDD/PDD, PTSD/CPTSD, GAD, OCD, or Bipolar II (depressive phase)
  • Has not responded to at least two evidence-based treatments
  • Is 18+ and under physician or psychiatrist care
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Not appropriate if:

  • Active psychosis, mania, or schizophrenia
  • Pregnancy, breastfeeding, or planning pregnancy within 12 weeks
  • Uncontrolled hypertension or acute cardiovascular disease
  • Active severe substance use disorder
  • Neurocognitive disorders or dementia
  • Previous negative response to psychedelic-assisted therapy