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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
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Date of Birth
What city do you live in?
What state do you live in?
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Alabama
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Arizona
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Florida
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South Carolina
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Texas
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Wyoming
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What category 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
Are you between the ages of 18 and 35 (inclusive)?
Yes
No
Date of Birth:
Have you been diagnosed with schizophrenia, schizophreniform, or schizoaffective disorder by a medical professional?
Yes
No
Have you experienced your first episode of psychotic illness within the last two years?
Yes
No
Were you intoxicated with alcohol during your first episode?
Yes
No
Have you been diagnosed with an alcohol or substance use disorder in the past 6 months?
Yes
No
In the past 6 months, how often have you consumed alcohol?
I do not consume alcohol.
Less than once a month.
Once a month or less.
2-4 times a month.
2-3 times a week.
4 or more times a week.
Are you taking 2nd generation antipsychotic medications (examples include Olanzapine, Clozapine, Ziprasidone, etc.)?
Yes
No
Have you had any changes to your medication in the last 3 weeks?
Yes
No
Excluding schizophrenia-related disorders, do you have a history of any other clinically significant diseases or conditions such as epilepsy or significant head injury?
Yes
No
Are you currently pregnant (females only)?
Yes
No
N/A
Do you have any limitations or conditions that would prevent you from safely undergoing an MRI scan, such as having non-removable metal objects in your body (e.g., pacemaker or metal implants) or experiencing claustrophobia?
Yes
No
Would you be willing to abstain from taking sedatives or anxiolytics on the day of the study assessment? This includes medications that are typically used to induce sedation or reduce anxiety.
Yes
No
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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