MDD Studies

Do you consent to the collection and processing of your personal data (including information about your race and ethnicity (as applicable), and your health information, including symptoms, diagnoses, medications, and treatments and our sharing of this information (“Health Data”) for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested, and disclosure to our Research Partners? You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed, or processed based on your consent. If you do not consent to the collection and use of your Health Data in this manner, we will not be able to provide you with our services or evaluate your eligibility to participate in the studies. *

Yes

First Name *

Last Name *

Phone Number *

Email *

Date of Birth MM/DD/YYYY *

Zip Code or Postal Code *

What sex were you assigned at birth? *

Have you been diagnosed by a doctor with Major Depressive Disorder (MDD)? *

Are you currently experiencing symptoms of depression (such as a persistent feeling of sadness and loss of interest in things you normally enjoy)? *

When did your current depressive episode start? *
Please note: A depressive episode is a period of two weeks or longer in which a person experiences certain symptoms of major depression: feelings of sadness and hopelessness, fatigue, weight gain or weight loss, changes in sleeping habits, loss of interest in activities, or thoughts of suicide.

Are you currently taking an antidepressant medication for your depression? *

In your current depressive episode, have you taken an antidepressant medication for at least 6 weeks? *

Please note: A depressive episode is a period of two weeks or longer in which a person experiences certain symptoms of major depression: feelings of sadness and hopelessness, fatigue, weight gain or weight loss, changes in sleeping habits, loss of interest in activities, or thoughts of suicide.

Have you previously taken an antidepressant medication during your current episode of depression? *

Is this current antidepressant medication helping with the symptoms of your depression? *

You mentioned little to no improvement with your current or recent antidepressant. Was it escitalopram (Lexapro) or citalopram (Celexa)? *

Within the past 12 months, have you tried 2 courses of antidepressant medications for at least 6 weeks? *
Please note: "2 courses of antidepressants" refers to trying two different antidepressant medications, each for at least 6 weeks.

Were the 2 courses of antidepressant medications taken for your current depressive episode? *

In the past 12 months, have you been diagnosed by a doctor with a personality disorder? *
Examples of personality disorders are: Borderline personality disorder, antisocial personality disorder, avoidant personality disorder, paranoid personality disorder, schizoid personality disorder.

Have you ever been diagnosed by a doctor with any of the following psychiatric disorders? *
Select all that apply.

Bipolar disorder (or Manic Depression)

Neurocognitive disorder

Borderline personality disorder

Antisocial personality disorder

Other personality disorder

Schizophrenia

None of the above

Unsure

Other

Do you have a history of epilepsy or seizures, other than a single seizure? *

Are you currently diagnosed by a doctor and experiencing any of the following disorders? *
Select all that apply.

Obsessive compulsive disorder (OCD)

Epilepsy

Alcohol or substance use disorder with the past 12 months (excluding nicotine)

Eating disorder (including Anorexia Nervosa and Bulimia Nervosa)

Panic disorder

None of the above

Unsure

Other

In the past 3 years, have you been diagnosed by a doctor with anorexia nervosa, bulimia nervosa, or binge eating? *

Have you been diagnosed (by a doctor) with any other medical conditions? *
(For example: Bipolar Disorder, schizophrenia, schizoaffective, schizophreniform, OCD, PTSD, uncontrolled diabetes mellitus, acute stress disorder, adjustment disorder, impulse control disorder, cancer, kidney disease, liver disease, unstable coronary artery disease, COPD, seizures, epilepsy, substance use disorder, suicidal ideation, seizure, skull fracture, cerebral contusion, cerebral hemorrhage, congestive heart failure, HIV, chronic hepatitis B or C)
Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

Have you ever received treatment with Electroconvulsive Therapy (ECT), vagus nerve stimulation, or transcranial magnetic stimulation (TMS) for your depression? *

During your current episode of depression, have you received treatment with Electroconvulsive Therapy (ECT), vagus nerve stimulation, or transcranial magnetic stimulation (TMS) for your depression? *

Have you started psychotherapy (also known as talk therapy) within the last 3 months? *

Have you been diagnosed or are currently suffering from a substance (excluding nicotine) or alcohol use disorder (also known as substance or alcohol addiction) within the last 12 months? *

Please list the medications you are currently taking for your depression. *
Please only include medications which have been prescribed by a doctor.
Please list here or write 'none'.

Are you currently taking any medications for your health conditions? *
Please list them below or type ‘none’.

Have you received ketamine or esketamine (e.g. SPRAVATO®) treatment within the past 2 years, or Salvinorin A within the last 6 months? *
Salvinorin A is a hallucinogen that may cause symptoms of hallucinations and dissociation.

Do you use cannabis (also known as marijuana)? *

Are you willing to avoid marijuana, CBD oil, and other cannabinoid use for the duration of the study? *

If qualified for the study, would you be willing and able to attend weekly visits over a period of 14 weeks? *

Please, select your height from the dropdown below. *

How much do you weigh in Lbs (pounds)? *

If female, are you currently pregnant, breastfeeding, or planning to become pregnant? *

Which racial or ethnic group(s) do you identify with? *
Please select all that apply.

American Indian or Alaskan Native

Asian

Black or African American

Hispanic Latino or Spanish

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Another race or ethnicity

I prefer not to answer

In the past 6 months, have you participated in a clinical research trial for an investigational drug? *

Are you currently participating in another Clinical Trial? *

What is the best day/time and method to reach you by (telephone or email) (we know you are busy)? *

Do you consent to receive recurring messages at the phone number you provided above, including SMS/MMS text messages, sent by or on behalf of AutoCruitment through the use of an autodialer or artificial intelligence with information about research studies for which you may be eligible? To opt out, reply “STOP”. For customer care or support, text “HELP”. Message and data rates may apply. Message frequency varies. By clicking “Yes”, you also agree to our SMS Terms and Privacy Policy. *

yes no

Consent for Medical Records Retrieval

By selecting “Yes” and submit below, you consent to our use and disclosure of your personal information as necessary to obtain a copy of your electronic medical records, including but not limited to your medical history, test results, treatment plans, diagnoses, prescriptions, and any other information contained in those records as necessary to provide our services to you. This medical record information will be shared with our service providers and clinical research sites in order to provide our services, including to determine your eligibility for clinical research studies. *

You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed or processed based on your consent.

The information you are providing here will be processed in accordance with our Privacy Policy, which describes our data privacy practices, including how we share your information with our Research Partners and use your information to send you details about potential clinical trial opportunities. When you submit this information, you consent to AutoCruitment’s use of your data as described in our Privacy Policy. If you have any questions regarding the handling of the information you have provided to AutoCruitment, or if you would like to make any changes or withdraw your consent, please contact us at info@autocruitment.com.

Join a research study evaluating potential new treatments for Depression

Clinical trial participants should:

Participation overview: