RivusInstitute.com - Depression Study Form

Fill this form to request info about Depression study
Name*

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Email*
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Address

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Birthday*

MonthDayYear
Date
Sex*

MaleFemaleN/A
Medical Conditions (check all that apply)*

No Medical ConditionsAddictionADHD (Attention Deficit Hyperactivity Disorder)AnxietyArousal DisorderBi-PolarBorderline Personality DisorderDementiaDepressionOpioid AddictionPost Traumatic Stress Disorder (PTSD)Tourette's SyndromeTreatment Resistant Depression
Medications & Treatments(check all that apply)*

NoneAdderallAmbienAmitriptylineArmor ThyroidAshwaghandaB ComplexBuSparBuspironeCELEXAClonazepamClozapineCymbaltaDepakoteDiazepamDuleraEffexorFluoxetineGabapentinGeodonHaldolHaloperodolHydrochlorothiazide (HCTZ)HydrocodoneInvegaKlonopinLatudaLexaproLisinoprilLithiumLorazepamLortabLyricaMarijuanaMeloxicamMethadoneNone ReportedOther/Not ListedOxycodonePaxilRexulti (brexpiprazole)RisperidoneRitalinSaphrisSeroquelSertralineSprintecSuboxoneSubutexToviazTrihexiphinidylViibrydVraylarVyvanseWellbutrinXanaxZiprasidoneZoloft
Are you 18 years of age or older? (1)*
Are you willing and able to commit to participating in a 5 year long study?*
Are you currently receiving, or have you previously sought, treatment for depression? (2)*
Have you attempted to resolve your depression at least four times by one or more of the following: medication(s), counseling/therapy, electro-convulsive therapy (ECT), or trans-magnetic stimulation (TMS)? (2)*
Female Only: If of childbearing potential are you willing to use birth control during the duration of the study? (5)
Are you willing to undergo outpatient surgery and have a device implanted?*
Do you currently have Medicare or Medicare Advantage?*
Have you attempted suicide within the previous 6 months?*
Have you been diagnosed with Alzheimer’s / dementia?*
Female Only: Are you currently pregnant or breastfeeding?*
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Provide Additional Comments & Types of Research Studies You'd Be Interested In*
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Fill this form to request info about Depression study

All information provided is confidential and will not be given or sold to any other agency without prior consent.