Within each of us lies an inner source for self-healing and wisdom

    Innersource,  a community of professionals providing psychotherapy and holistic healing

980 Awald Road
Annapolis, MD 21403


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         Physician Approval Form

The Genecept Assay Physician Approval Form

The Genecept Assay is a comprehensive saliva-based genetic test that helps
guide treatment decisions and increases treatment response for patients with
psychiatric disorders.

The Genecept Assay looks at key genes in your body that affect how it responds
to medications. It includes pharmacodynamic genes so that treatment decisions
can be personalized to the individual. These genes analyzed are associated
with a wide range of psychotropic medications and can help inform treatment
plans for depression, anxiety, OCD, ADHD, bipolar, PTSD, schizophrenia,
chronic pain, and substance abuse.

This assay looks at genetic changes that give a predisposition to metabolism
changes for medications processed through the CP450 pathways. It can be
helpful when starting patients on psychiatric medications or making changes to
current regimens. At Innersource, we are able to perform this test and get the
results back to the treating clinical provider.

If you feel your patient would benefit from this assay we will schedule a testing
date at InnerSource in Annapolis, MD.

After the results are complete, we will forward a copy of the test to your office.

Please copy this form and have your physician sign it. Then Fax it to the
number below.

For a PDF copy of the form, please CLICK HERE

Patient Name (please print):____________________________________________________

Physician Name:_____________________________Signature:_______________________

Office address:______________________________________________________________

Phone #_________________________Fax#_______________________________________

Email Address:______________________________________________________________

More info?     Go to www.genomind.com/clinicians

Fax the completed form to: Abby Rosen Ph.D at:  410-267-0280

Abby Rosen Ph.D

InnerSource 980 Awald Rd., Annapolis, MD 21403



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