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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
Other
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Date of Birth
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What city do you live in?
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What state do you live in?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Select all of the following that best describes you:
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish origin
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Which of the following psychiatric conditions have you been diagnosed with?
Depression
Anxiety
Bipolar disorder
Schizophrenia or related condition
OCD
PTSD
Borderline personality disorder
Antisocial personality disorder
Other
None of the above
Are you currently depressed?
Yes
No
Have you tried one or more medications for your current depression without improvement in symptoms?
Yes
No
N/A- I have not taken any medication for depression
Have you received electroconvulsive therapy (ECT) or ketamine treatment for your current episode?
Yes
No
Do you currently have ongoing care with a mental health provider? This could include regular therapy sessions, medication management, or other mental health support services.
Yes
No
How long has this episode of depression been?
Less than 1 month
1-2 months
3-6 months
7-12 months
1-2 years
3+ years
What is your dominant hand?
Right
Left
Ambidextrous
Are you currently dependent on any substances, such as alcohol or non-prescribed drugs?
Yes
No
Which of the following statements apply to your pregnancy status or experience?
Not pregnant/Not applicable
Currently pregnant
Planning to become pregnant in the near future
Recently gave birth
Currently breastfeeding
Are you native English speaker?
Yes
No
Do you have any limitations that would prevent you from safely undergoing an MRI scan, such as having non-removable metal objects in your body (implants, pacemakers, etc.) or experiencing claustrophobia?
Yes
No
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BCFS001324
