Confidential PreScreening Form : 

 

 

Personal Information

First Name (required):
  Last Name (optional):
  City of Residence (optional):
 
State:
 Zip Code (both optional):
 

 

Contact Information
Please contact me at
(at least one is required):

Home phone:
  Work phone:
  Cell phone:
  E-Mail address:
 

 

Area of Interest
I am interested in participating in a study on (check as many as may be applicable):

Depression
  Bipolar Disorder
  Anxiety
  Insomnia
  Alzheimer’s Disease
  Pain
 

other

 

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We will contact you to let you know if we are currently or will soon begin a study of one of these disorders.

Please note that all measures are taken to protect confidentiality, however, it cannot be guaranteed that the Internet is completely free from risk of interception of information from someone other than the intended recipient.

 

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"I have been doing clinical research for more than 20 years and think it is a wonderful way to advance our knowledge about the art and science of helping people."


Norman Rosenthal, M.D.
CCRA Medical Director

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