Reunion AjD Eligibility Survey

1
Kadima Neuropsychiatry Institute specializes in providing advanced treatments for mental illness. We are also conducting research to develop innovative treatments.

We are seeking participants for a clinical study investigating an experimental psychedelic compound for the treatment of Adjustment Disorder in Cancer and Parkinson's patients.

The sponsor of this study is Reunion Neuroscience, and the Principal Investigator is David Feifel, MD, PhD. The research is being conducted at Kadima Neuropsychiatry Institute, located in La Jolla, California.

Participants will be compensated for their time and travel expenses.

If you are interested in being considered for this study, please complete the following brief survey to determine your initial eligibility. It should take about 3 minutes to complete.

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
How did you hear about us?* This field is required.
Billboard
Email/ Newsletter
Physical Flyer / Brochure
Social Media Ads
Social Media Post (Not an AD)
Family/Friend Referral
Provider Referral
Advertisement
Media (Magazine, News, TV)
Our Website
Event (Conference, speaking engagement, etc)
Online Search
ClinicalTrials.Gov
Not Sure
Other
4
Please provide an email to contact you about your eligibility* This field is required.
example@example.com
5
Please provide a phone number to contact you about your eligibility* This field is required.
Please enter a valid phone number.
6
Are you currently a Kadima patient, or have you been a patient in the past?
YESNO
7
Have you recently been diagnosed with cancer?* This field is required.
YESNO
8
Have you recently been diagnosed with Parkinson's disease ?* This field is required.
YESNO
9
Have you been feeling unusually anxious, sad, or overwhelmed since your diagnosis?* This field is required.
YESNO
10
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
11
PHQ 2 Score
12
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
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
13
Gad-2 Score
14
Are you currently taking an antidepressant medication?
YESNO
15
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
16
Please provide any relevant additional comments or clarifications
Huge
Large
Normal
Small
Ok
Ok
17
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
18
Get Page URL
19
Referrer
20
Should be Empty: