Short Social Media Eligibility Survey (COMP)

1
Kadima Neuropsychiatry Institute specializes in providing advanced treatments for mental health. We are also conducting research to develop innovative new treatments, such as psychedelics.

KADIMA is seeking participants for a clinical study of the
investigational drug BPL-003 (aka 5-MeO-DMT) for Treatment-Resistant Depression (TRD).

The principal investigator at our site is DAVID FEIFEL, MD, Ph.D.

The following survey will assess your current eligibility to participate in this trial. This survey should take approximately 3 minutes to complete.
Please answer as honestly and as completely as possible.

This survey platform is HIPAA-compliant and designed to protect your protected health information (PHI).
Information entered will only be used for the purposes of eligibility assessment by KADIMA Research Staff members.
2
Please enter your name* This field is required.
First Name
Last Name
3
What is your date of birth? * This field is required.
Date
Month
Day
Year
4
How did you hear about us?* This field is required.
Email/ Newsletter
Social Media Ads
Social Media Post (Not an AD)
Family/Friend Referral
Provider Referral
Advertisement
Media (Magazine, News, TV)
Physical Flyer / Brochure
Billboard
Our Website
Event (Conference, speaking engagement, etc)
Online Search
ClinicalTrials.Gov
Not Sure
Other
5
Please provide an email to contact you about your eligibility* This field is required.
example@example.com
6
Please provide a phone number to contact you about your eligibility* This field is required.
Please enter a valid phone number.
7
Are you currently a Kadima patient, or have you been a patient in the past?* This field is required.
YESNO
8
Have you been diagnosed as having clinical depression (formally know as Major Depressive Disorder) by a mental health professional such as a psychiatrist, licensed therapist, etc.* This field is required.
YESNO
9
Over the last 2 weeks, how often have you been bothered by any of the following problems? please select the circle to indicate your answer* This field is required.
Not at All
Several Days
More than half the days
Nearly every day
Little Interest or pleasure in doing things
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Feeling down, depressed, or hopeless
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Little Interest or pleasure in doing things
Feeling down, depressed, or hopeless
Not at All
Row 0, Column 0
Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly every day
Row 0, Column 3
Not at All
Row 1, Column 0
Several Days
Row 1, Column 1
More than half the days
Row 1, Column 2
Nearly every day
Row 1, Column 3
1 of 2
10
PHQ 2 Score
11
Participants in this study must discontinue all prescribed psychiatric medication before receiving the study drug. Would you be willing to discontinue them? (under the supervision of a study physician)* This field is required.
Yes
No
N/A - Not on any prescribed medication
12
Which medication are you unwilling to discontinue?* This field is required.
13
If selected for the study, are you able to come to Kadima's location in La Jolla, CA (near UCSD campus) for in-person visits?* This field is required.
YESNO
14
Please provide any relevant additional comments or clarifications that you think are relevant
Huge
Large
Normal
Small
Ok
Ok
15
Would you like to be contacted about future research opportunities at Kadima which you may qualify for and potential therapeutic options that may suit your needs?* This field is required.Your information will be kept in a HIPAA-compliant database. You can contact us anytime at research@kadimanp.com to have your information removed.
YESNO
Should be Empty: