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 *

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 with bipolar disorder or major depressive disorder (MDD)? *

Yes - diagnosed with bipolar disorder

Yes - diagnosed with MDD

No - not diagnosed with either bipolar disorder or MDD

Unsure

Do you often feel uninterested or unmotivated in your daily activities? *

Yes - lack of interest or motivation in daily activities

No

Unsure

Are you currently experiencing a depressive episode? *

Yes - currently experiencing a depressive episode

No

Unsure

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.

In the past 12 months, have you experienced hallucination or delusion symptoms associated with your depression or bipolar disorder? *

Yes - experienced hallucination or delusion symptoms

No

Unsure

Hallucinations occur when someone sees, hears, or senses things that are not actually there.
Delusions are strong beliefs that are not based in reality, even when there is evidence that they are not true.

Have you ever been diagnosed with any of the following conditions? *
Please select all that apply.

Schizophrenia

Autism Spectrum Disorder

Bipolar Disorder

Attention deficit hyperactivity disorder (ADHD) diagnosed in the past 12 months

Anorexia nervosa diagnosed in the past 12 months

Bulimia nervosa diagnosed in the past 12 months

Binge eating disorder diagnosed in the past 12 months

Chronic fatigue syndrome diagnosed in the past 12 months

Obsessive compulsive disorder (OCD) diagnosed in the past 12 months

Post traumatic stress disorder (PTSD) diagnosed in the past 12 months

None of the above

Are you currently being treated with any of the following medications? *
Please select all that apply.

Valproate (Depakene® / Depakote®)

Lithium (Lithobid® / Eskalith®)

Lamotrigine (Lamictal™)

None of the above

Unsure

Have you been diagnosed (by a doctor) with any medical conditions? *
(For example: dementia, HIV, Hep B, Hep C)
Please list here or write 'none'
Please only include conditions which have been diagnosed by a doctor.

Have you had bariatric surgery? *

Yes No

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

Please, enter your height below. *

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

Are you currently pregnant or breastfeeding? *

Yes - pregnant

Yes - breastfeeding

No

N/A

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

Mediterranean (Greek/Italian/Portuguese/Spanish/etc.)

Another race or ethnicity

I prefer not to answer

Capturing information on ethnic backgrounds allows us to better understand how different groups may have different needs.

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

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.