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Wise Therapeutics Social Anxiety Study
Thank you for your interest in this study researching treatment for people who experience anxiety in social situations.
10
Questions
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1
Are you aged 22-65?
*
This field is required.
This is a requirement to take part in the study.
YES
NO
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2
Please assign a rating to the following statements:
*
This field is required.
Use the slider to select between: Not at all; Slightly; Moderately; Very; Extremely. Please select an answer in every row to continue.
Being criticized scares me a lot
I would do anything to avoid being criticized
I am afraid of doing things when people might be watching
Not at all
Slightly
Moderately
Very
Extremely
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Moderately
Very
Extremely
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Slightly
Moderately
Very
Extremely
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Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Being criticized scares me a lot
I would do anything to avoid being criticized
I am afraid of doing things when people might be watching
Not at all
Slightly
Moderately
Very
Extremely
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Not at all
Slightly
Moderately
Very
Extremely
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Not at all
Slightly
Moderately
Very
Extremely
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
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3
Mini-SPIN-R
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4
Do you have a current diagnosis of ANY of the following: Post-Traumatic Stress Disorder (PTSD), Schizophrenia, Bipolar I or II, Borderline Personality Disorder (BPD), or Moderate to Severe Substance Use Disorder?
*
This field is required.
Unfortunately if the answer to this is "Yes", you will not be eligible to take part in the study.
YES
NO
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5
Have you attempted to kill yourself within the past 2 years OR thought about killing yourself within the past 30 days?
*
This field is required.
Unfortunately if the answer to this is "Yes", you will not be eligible to take part in the study.
YES
NO
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6
Do you have access to a mobile phone or tablet with a functional internet connection?
*
This field is required.
This is a requirement to take part in the study.
YES
NO
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7
Are you currently pregnant OR planning to become pregnant within the next 1-3 months?
*
This field is required.
Unfortunately if the answer to this is "Yes", you will not be eligible to take part in the study.
YES
NO
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8
Great, you're likely to be eligible for this study! Do you consent to the information entered here being stored by Lindus Health, subject to the terms of our
privacy policy
, and being shared with the research team?
*
This field is required.
This is required so that the study can contact you with further details about participation. We will never share your data without your explicit consent. We may contact you about relevant future research opportunities, and you can opt out of this at any time.
YES
NO
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9
What is your name?
*
This field is required.
In the following questions we will just ask for your name, email, and phone number so that the research team can contact you.
First Name
Last Name
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10
And what's your email address?
*
This field is required.
In the following questions we will just ask for your name, email, and phone number so that the research team can contact you.
example@example.com
Confirm Email
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11
And finally, your phone number?
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This field is required.
Your mobile number will only be shared with the research team to contact you about this study.
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