Depression Study Website

Fields marked with an * are required.

First Name *

Last Name *

Phone number *

Date of Birth MM/DD/YYYY *

ZIP or Postal Code *

What is your Gender? *

Have you been told by a doctor that you have depression, or bipolar depression? *

Yes – I have depression

Yes – I have bipolar depression

No – I do not have a formal diagnosis

Have you been under the care of a psychiatrist or other mental health professional in the last 3 years? *

Are you currently experiencing an episode of Depression? *

Have you been experiencing this current episode of Major Depression for at least 8 weeks? *

Have you been experiencing this current episode of depression for at least two years, or had recurring episodes of depression? *

Are you currently taking medications or other treatments (can include medications, psychotherapy, magnetic stimulation or electroconvulsive therapy) for your depression? *

Are you currently taking an antidepressant medication for your Major Depression? *

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

Has this medication helped with the symptoms of your Major Depression? *

Have you tried at least four depression treatments and not found them helpful? *
(Can include medications, psychotherapy, magnetic stimulation or electroconvulsive therapy)

Have you been diagnosed (by a doctor) with any other medical conditions? *
(For example: Schizophrenia, Schizoaffective Disorder, Schizophreniform Disorder, Bipolar Disorder, Hepatitis B or C, Epilepsy, Seizures, HIV).
Please list here or write 'none'
Please only include conditions which have been diagnosed by a doctor.

Please list the medications you are currently taking for your depression. *
Please list here or write 'none'.

Please, select your height from the dropdown below. *

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

If female, are you currently pregnant or breastfeeding?

Are you currently insured by Medicare or a Medicare plan managed by a commercial insurer, sometimes called a Medicare Advantage plan? *

Would you consider a surgical procedure / implanted device as an alternate treatment for your depression? *

Would you like to be contacted about taking part in a clinical research study (also known as a clinical trial)? *

Yes

What is the best day/time to reach you via telephone (we know you are busy)? *

The information you are providing here will only be used to match you to a clinical research study in the potential participant’s area and contact you to see if you would like to participate. Please note the information you enter will be kept private, except when ordered by law, and only accessible to our Clinical Research Partners and affiliates and applicable regulatory agencies. If you have any questions regarding the handling of the information you have provided to autocruitment.com, or if you would like to make any changes, please contact us at info@autocruitment.com.