Please print, fill out, and bring to your first appointment one of the following forms:

Adult Psychiatric Intake Form (for adults)

Child-Adolescent Psychiatric Intake Form (to be filled out by legal guardian for minors)

Please also print, fill out, and bring to your first appointment the following forms:

Consent to Treatment/Release of Information Form

Payment Authorization 

PHQ-9

PHQ-9 for Adolescents

GAD-7

Mood Check

If you are seeking help for diagnosed or suspected ADHD, in addition please fill out the following forms:

Diagnostic Interview for ADHD in Adults (DIVA 2.0)

Adult ADHD Self-Report Scale (ASRS-v1.1)

You may be asked to fill out some of the forms below and/or if there are forms listed in a category that seems applicable to the work you anticipate doing with Dr. Jain, please feel free to fill them out and bring them to your session.

Depression

PHQ-9

PHQ-9 Detailed Explanation

Depression Remission Questionnaire

Suicide Intent Scale

Chronic Treatment Resistant Depression

Adverse Childhood Experiences Questionnaire (ACE Questionnaire)

PTSD with Life Events Checklist

Difficulties In Emotional Regulation (DERS)

Anxiety

GAD-7

The Anxiety Worksheet

Health Anxiety Assessment 

Bipolar Disorder

Mood Disorder Questionnaire (MDQ)

Mood Check (for bipolar disorder)

Daily Mood Tracker

Ketamine Assisted Psychotherapy

What is Psychedelic Assisted Psychotherapy?

Ketamine Assisted Psychotherapy (KAP) Informed Consent

KAP Intake Form

KAP Preparation and Aftercare Guide

Post-KAP Integration Recommendations

Post KAP Session Log

Sexual Functioning

Sexual Experience Scale

Sleep

Insomnia Severity Index

Sleep Hygiene

Wellness

WHO-5 Well-Being Questionnaire

HERO Wellness Scale

Borderline Personality Disorder

Borderline Personality Disorder Explained

Borderline Personality Screener

Borderline Personality Disorder in Adolescents

Dialectical Behavioral Therapy explained (one hour webcast)

Blank Diary Card 

Blank Chain Analysis Worksheet

BPD vs. Bipolar Disorder 

Emotional Vulnerability and Distress Intolerance 

General Practice Forms

Notice of Privacy Practices

Practice Guidelines

Other Resources

Recommended Books