Fields marked with an * are required.

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 * Please enter your phone number

Email *

Date of Birth MM/DD/YYYY *

Zip Code *

What sex were you assigned at birth? *

Male

Female

Prefer not to say

Have you been diagnosed by a doctor, psychiatrist, or psychologist with Bipolar I or Bipolar II disorder? *

Yes - diagnosed with Bipolar I disorder

Yes - diagnosed with Bipolar II disorder

No

Unsure

Are you currently experiencing a depressive episode? *
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.

Yes - currently experiencing a depressive episode

No

Have you been diagnosed (by a doctor) with any other medical conditions? *
Please list here or write 'none'. 
Please only include conditions which have been diagnosed by a doctor.

Are you currently taking any medications or receiving treatment to treat Bipolar Disorder? *

Yes - currently using medications or treatment for BPD treatment

No

Are your current medications or treatments for bipolar disorder effectively improving your symptoms? *

No - little to no improvement of BPD symptoms

Yes

Unsure

Are you taking any medications or treatments for any other health conditions? *
(For Example: bariatric surgery, clozapine, carpiprazine, fluconazole, ketoconazole, clarithomycin, rifampin, carbamazepine, phenytoin, St. John’s Wort) 
Please list them below or type ‘none’.

Have you ever had bariatric (gastric bypass) surgery? *
Bariatric surgery, including gastric bypass, is a medical procedure that helps with weight loss by changing how the stomach and digestive system work.

Yes - bariatric surgery

No

Unsure

Are you willing to refrain from the use of Marijuana for the duration of the study? * 
The study duration is approximately 30 weeks. Urine drug screen is performed at each visit.

Yes - willing to refrain from Marijuana use

No

N/A - I do not use Marijuana

Unsure - I would like to discuss this further

Are you currently participating in another Clinical Trial? *

No

Yes - participating in another clinical trial

Are you currently pregnant, breastfeeding, or planning to become pregnant? *

Yes - pregnant / breastfeeding / planning to become pregnant

No

If sexually active, are you post-menopausal or willing to use a method of birth control (such as a condom, IUD, or contraceptive pill) for the duration of the study? *
The study duration is approximately 30 weeks.
If you experience permanent sterility or permanent infertility (due to being postmenopausal, having undergone a hysterectomy/bilateral salpingectomy/bilateral oophorectomy, or from an alternative medical cause) please state that this is Not Applicable.

Yes - willing to use method of birth control

N/A

No

Unsure - I would like to discuss this further

What is the best day/time to reach you via telephone (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.

Yes No

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.