Research Study Questionnaire
Consent Form
It is mandatory that the consent form below must be thoroughly read and signed before taking part in this research study. Then upload it back here and check the box.
If you're using a mobile device and unable to print and sign the consent form, you can sign below here:
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Date Of Birth
*
*As stated in the consent form you must be 18 or older to participate in this research study.
Gender(s)
*
Male
Female
Other
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Specific Phobia
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) there are 5 different subtypes of Specific Phobia. Please select the one that corresponds with your phobia, if you're unsure please state below.
Please select the subtype of specific phobia that corresponds with you:
*
Animal Phobia (spiders, snakes, insects…)
Natural Environment (storms, water, trees…)
Situational (elevators, tunnels, flying, driving…)
Medical/Blood-Injury (needles, blood/injury…)
“Other” (choking, vomiting, germs…)
State here if unsure:
If applicable please provide proof of your specific phobia diagnosis from a licensed professional or explain down below:
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*This is not a mandatory requirement but please provide proof if available.
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What age were you diagnosed with your specific phobia?
*If unsure leave blank
Do you have any family history of specific phobias?
*Please provide any information of specific phobia in your family, if applicable. However, do not reveal their identity.
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Severity Measure for Specific Phobia
Below is a severity measure for Specific Phobia in the form of a likert scale. Click the link below, fill it out, upload it back here, and check the box.
Upload here:
*
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Substance-Use Disorder
A substance-use disorder (SUD) is a mental disorder that affects a person’s brain and behavior, leading to a person’s inability to control their use of substances such as legal or illegal drugs, alcohol, or medications. Symptoms can range from moderate to severe, with addiction being the most severe form.
For this research study suffering from a Substance-Use Disorder is not a requirement. It can be an addiction or very minimal usage. If you do deal with any substance(s) please select below:
*
Alcohol
Illegal Drugs
Medications
Cannabis
N/A (I do not have a SUD)
Other
Do you have any family history of Substance-Use Disorder?
*Please provide any information of anyone in your family who has an addiction of any type of substance, if applicable. However, do not reveal their identity.
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Email
Please type your email address below. It will only be used if further contact is needed for follow-up questions.
Email
*
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In order to keep your identity anonymous you will be creating a "cover name" that only you will have knowledge of.
Your anonymity is our priority.
Create your code name...
*
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