Mental Health Clinical Trial Pre-Screening
Personal Information
Full Name
Age
Gender
Female
Male
Non-binary
Other
Prefer not to say
Contact Email
General Health
Have you been diagnosed with any mental health condition?
Yes
No
Unsure
If yes, please specify the diagnosis
Are you currently receiving treatment?
Yes
No
Are you currently taking any psychiatric medication?
Yes
No
If yes, please list the medication(s)
Eligibility & Screening
Have you previously participated in a clinical trial?
Yes
No
Are you available for in-person visits?
Yes
No
Maybe
Additional Information (optional)