MDD Study

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 *

Are you Male or Female? *

Female

Male

Prefer not to say

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

Yes - diagnosed with MDD

Are you currently experiencing any of the following symptoms of depression? *
Please select all that apply…

Persistent feeling of sadness or emptiness

Loss of interest in things I normally enjoy

Lack of sleep or too much sleep

Lack of energy

Lack of concentration or poor memory

Agitation / outburst / frustration

None of the above

Did your depression symptoms start as a result of experiencing a personal situation or event (loss of loved one, homelessness, divorce, traumatic injury, etc?) *

Yes – depression symptoms started after personal event

Did your current depressive episode start more than 4 weeks ago? *
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 – More than 4 weeks ago

Unsure

Within the past 12 months, have you tried 2 different 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.

Yes No

In the previous question you reported taking 2 different antidepressants for at least 6 weeks in the past 12 months. How many antidepressants were taken for your current depressive episode? *

2 – Both antidepressants were taken for my current depressive episode

1 – Only 1 antidepressant was taken for my current depressive episode

0 – No antidepressants were taken for my 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.

Yes No

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

Bipolar disorder

Obsessive-compulsive disorder (OCD)

Schizophrenia

Post-traumatic Stress Disorder (PTSD)

Alcohol or substance use disorder

None of the above

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

Yes No

Have you been diagnosed (by a doctor) with any other medical conditions? *
(For example: 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)
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? *

Yes No

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.

Yes No Unsure

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

Yes

Unsure - I would like to discuss this further

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? *

Yes 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 Latino or Spanish

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Another race or ethnicity

I prefer not to answer

Do you identify as Hispanic? *

No Yes

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.