MMED Emerge (MDD) Short Survey

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Eligibility Survey

Kadima Neuropsychiatry Institute is seeking participants for a clinical study of the
investigational drug MM120 (a pharmaceutical formulation of LSD) for Major Depressive Disorder (MDD).

The sponsor of this study is Mind Medicine Inc. The principal investigator at our site is David Feifel, MD, Ph.D. This study is taking place at Kadima's location in La Jolla, CA.

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. Responses will be verified at the next stage through your medical records and/or in-person assessments.

You can find more information about this study here.

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.
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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)
Billboard
Family/Friend Referral
Provider Referral
Advertisement
Media (Magazine, News, TV)
Physical Flyer / Brochure
Our Website
Event (Conference, speaking engagement, etc)
Online Search
ClinicalTrials.Gov
Not Sure
Other
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What is your email?* This field is required.
example@example.com
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What is your preferred phone number?* This field is required.
Please enter a valid phone number.
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Are you currently a Kadima patient or have you been a patient in the past?* This field is required.
YESNO
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Have you been diagnosed as having Major Depressive Disorder(MDD) by a mental health professional such as a psychiatrist, licensed therapist, etc. ?* This field is required.
YESNO
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Have you been diagnosed as having Generalized Anxiety Disorder (GAD) by a mental health professional such as a psychiatrist, licensed therapist, etc. ?* This field is required.
YESNO
10
Over the last 2 weeks, how often have you been bothered by any of the following problems? * This field is required.please select the circle to indicate your answer
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
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PHQ-2 Score
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Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.please select the circle to indicate your answer
Not at All
Several Days
More than half the days
Nearly every day
Feeling nervous, anxious or on edge
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Not being able to stop or control worrying
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
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
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GAD-2 Score
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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
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Please provide any relevant additional comments or clarifications that you think are relevant
Huge
Large
Normal
Small
Ok
Ok
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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
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Get Page URL
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Referrer
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