Skip to content
Screening Form
Please complete the screening form below
Displayed
First Name
Displayed
Last Name
Phone Number
Email Address
Hidden
Gender
Male
Female
Displayed
Date of Birth
What city do you live in?
What state do you currently 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
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Which 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
What is your gender?
Male
Female
Other
Are you in a treatment program or seeing a therapist for alcohol use?
Yes
No
What type of treatment program are you attending?
Inpatient: Living at a rehab facility full-time
Outpatient: Going to therapy or a day hospital while living at home
What is the name of the treatment facility you attend?
Upon finishing this program, do you plan on continuing treatment at a residential program (where you will be living there for a period of time)?
Yes
No
Are you currently pregnant or planning to become pregnant in the next 6 months?
Yes
No
In the past 6 months, have you experienced any psychotic symptoms, such as hallucinations or delusions?
Yes
No
Do you own a smartphone?
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.
Displayed
Captcha
Submit
Terms of Service
Privacy Policy
Terms of Service
Privacy Policy
Tagged
BCFS00941
