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Screening Form
Please complete the screening form below and our team will be in touch. Thank you!
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First Name
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Last Name
Phone Number
Email Address
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Gender
Male
Female
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Date of Birth
What city do you live in?
How old are you?
14–17
18–21
Parent First Name
Parent Phone Number
Parent Email Address
Do you have braces or any non- removable piercings?
Yes
No
Are you eligible to receive payment in the United States?
Yes
No
Do you read and speak English fluently?
Yes
No
Are you under the care of a clinician (ex. Primary care physician, nurse practitioner, psychiatrist, etc.)?
Yes
No
Have you recently been experiencing sad or irritable moods? Or have you lost interest in your activities?
Yes
No
Are you planning on starting antidepressant treatment or interested in starting antidepressant treatment?
Yes
No
Are you taking any antidepressants, mood stabilizers, hormone supplements or steroids?
Yes
No
Do you take any stimulant medications (ex. Adderall, Ritalin, etc.)?
Yes
No
Do you have any learning disabilities?
Yes
No
Do you have any first degree relatives who have been diagnosed with or suspected to have bipolar disorder or schizophrenia?
Yes
No
Do you have any definite plans to move away from the Los Angeles area?
Yes
No
When is the best time to reach you?
Mornings (9am-12pm)
Afternoons (12pm- 4pm)
Evenings (4pm-7pm)
You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.
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BCFS00550