Request appointment | Jain Medical Psychiatry

Jain Medical Psychiatry

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Reason for care

Select date & time

1 Appointment info

2 Prescreener

Reason for care

3 Contact information

What is the reason for seeking care?

Anxiety Attentional difficulties (ADHD) Behavioral issues Depression Schizophrenia Relationship issues Substance use Trauma Other

What kind of care is being sought?

Medication Other Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Have you ever have been psychiatrically hospitalized in your life?

Yes No

Have you ever attempted suicide?

Yes No

Please list all current medications.

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What is your height?

What is your weight?

Do you have any significant legal problems in the past or any legal problems ongoing at this time (i.e. court cases, divorce, arrests etc.)

Yes No

History of mental illness in the family?

Yes No

Your Preferred Pharmacy (if you know)

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

Jain Medical Psychiatry

646.801.0551

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.