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

Have you been diagnosed by a doctor with generalized anxiety disorder (GAD) within the last 10 years? *

Diagnosed with GAD within the last 10 years

Diagnosed more than 10 years ago

Never diagnosed

Unsure

Do you currently experience any of the following symptoms? *
Select all that apply

Excessive worry or anxiety about multiple areas of life (work/school/family/health/daily responsibilities)

Difficulty controlling or stopping worries

Feeling restless

Feeling easily tired or fatigued

Difficulty concentrating or feeling that your mind goes blank

Feeling irritable or easily annoyed

Muscle tension (tight shoulders/neck pain/ clenched jaw/muscle tightness)

Difficulty falling asleep/staying asleep/unsatisfied with sleep

None of the above

Have you ever, at any time in your lifetime, received any of the following antipsychotic injectable treatments? *
Please select all that apply.

Fluphenazine decanoate (Modecate®)

Haloperidol decanoate (Haldol Decanoate®)

Aripiprazole monohydrate (Abilify Maintena®)

Aripiprazole lauroxil (Aristada®)

Olanzapine pamoate (Zyprexa Relprevv®)

Paliperidone palmitate (Invega Sustenna®/ Invega Trinza®/ Invega Hafyera®)

Risperidone long-acting injection (Risperdal Consta®)

None of the above

Unsure

A long-acting injectable antipsychotic medication is a shot that slowly releases medicine over time to help a person think more clearly and manage mental health symptoms, without needing to take pills every day.

Have you ever, at any time in your lifetime, been treated with any of the following therapies? *
Please select all that apply.

Ketamine (sometimes used as ketamine infusion therapy)

Esketamine (Spravato®)

Arketamine (investigational ketamine-related treatment)

None of the above

Have you undergone any of the following treatments in the past 2 years? *

Please select all that apply.

Psilocybin-assisted therapy ("magic mushroom" therapy)

MDMA-assisted therapy (ecstasy-assisted therapy)

None of the above

Have you ever received any of the following brain stimulation treatments? *

Please select all that apply.

Electroconvulsive therapy (ECT: uses small electric currents to help improve depression)

Deep brain stimulation (DBS: implanted device that delivers an electrical current to your brain)

Transcranial magnetic stimulation (TMS: uses magnetic pulses on the head to help brain areas linked to mood)

None of the above

In the past 12 months, have you taken any of the following medications? *

Please select all that apply.

Valproic acid (Depakote®)

Carbamazepine (Tegretol®)

Lamotrigine (Lamictal®)

Oxcarbazepine (Trileptal®)

Topiramate (Topamax®)

None of the above

The medicines below help keep a person's mood more balanced and can also help prevent seizures in some people.

In the past 12 months, have you taken any antipsychotic medication by mouth (oral antipsychotic)? *

Please select all that apply.

Haloperidol (Haldol®)

Chlorpromazine (Thorazine®)

Fluphenazine (Prolixin®)

Perphenazine (Trilafon®)

Thioridazine (Mellaril®)

Trifluoperazine (Stelazine®)

Prochlorperazine (Compazine®)

Risperidone (Risperdal®)

Olanzapine (Zyprexa®)

Aripiprazole (Abilify®)

Lurasidone (Latuda®)

Ziprasidone (Geodon®)

Quetiapine (Seroquel®)

Sulpiride (Dogmatil®)

None of the above

Antipsychotic medication is medicine that helps people think more clearly and can reduce confusion, unusual thoughts, or hearing and seeing things that are not there.

Are you taking any other medications or treatments for your health conditions? *
Please list them below or type ‘none’. (Examples: gastric bypass, gastric sleeve, oral antipsychotics or mood stabilizing medications)

At any time of your life, have you ever been diagnosed by a healthcare professional with any of the following conditions at any time in your life as your primary mental health condition? *

Please select all that apply.

Schizophrenia

Schizoaffective disorder

Delusional disorder

Bipolar disorder

Cyclothymic disorder

Dementia

Alzheimer's disease

Parkinsons Disease

Lewy Body Disease

Frontotemporal Degeneration

Obsessive-compulsive disorder (OCD)

Borderline personality disorder (BPD)

Antisocial personality disorder

Major depressive episode with hallucinations or delusions

None of the above

Have you been diagnosed by a doctor with any other medical conditions? *

Please list here or write 'none'

(For example: HIV, Hepatitis B, Hepatitis C, type 1 diabetes, neuroleptic malignant syndrome, serotonin syndrome, Schizophrenia, Schizoaffective disorder, Delusional disorder, Bipolar disorder, Cyclothymic disorder, Dementia, Alzheimer's disease, Obsessive-compulsive disorder, OCD, Borderline personality disorder, BPD, Antisocial personality disorder, major depressive episode with psychotic features)

What is your height? *

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

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

Yes - pregnant / breastfeeding / planning to become pregnant

No

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 or 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.