Clinical Associates would like to inform you that we have formed a collaboration agreement with Collective Medical Research which provides opportunities for patients to enroll in various clinical trials, including depression, anxiety and others. Qualified participants would receive free medications for the duration of the study, free labs, basic medical work up and a small stipend for their time. There will be no cost to you or your insurance company to participate. If you are currently a patient, you can continue to keep your appointments with your current provider at Clinical Associates. If interested, please fill out and submit the following questionnaire for a current study to indicate that you are interested in participating. One of the associates from Collective Medical Research will be in touch with you shortly.

Over the last two weeks how often have you been bothered by the following problems?

Please make a selection from the drop-downs.

A. Little Interest or pleasure in doing things.

B. Feeling down, depressed, or helpless

C. Trouble falling or staying asleep, sleeping too much

D. Feeling tired or having little energy

E. Poor appetite or overeating

F. Feeling bad about yourself - or that you are a failure or have let yourself or your family down

G. Trouble concentrating on things, such as reading the newspaper or watching television

H. Moving or speaking so slowly that the other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

I. Thoughts that you would be better off dead or of hurting yourself in some way

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Name

First Name

Last Name

Phone

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