We are conducting studies with a variety of individuals, including those who are experiencing certain changes in their mood, thinking, and school or work performance.
To find out if our study is a good fit for you, we do a "screening" which involves asking for some information about your experiences, medical history, and treatment history. This form is one option for sharing this information with us, and should take roughly 10 minutes. The information you share will be kept confidential within our clinical team and is saved electronically through the HIPAA-compliant REDCAP server at McLean Hospital..
The form requires you to submit some kind of identifier (your name, initial, or nickname), and an e-mail address, so you are providing us with some identifying information. We keep an electronic database of general information such as your age, gender, and how you found out about us to help track who is and is not interested in and eligible for our studies. However, we do not enter your name, phone number, address, or any other information that could specifically identify you into this database. If your responses suggest that you are eligible for the study, a clinician or research assistant will review your responses and follow up with you using the contact information you provide. If at any point you decide that you do not want to be contacted, you can exit the survey without submitting a response or email/call the researchers to opt out of future contact.
This form is voluntary and you may refuse to answer any question.
Please note that completing this electronic form is one way for us to get to know whether your experiences make you a good fit for our studies - if you would be more comfortable, you may also call or e-mail or us directly. If you prefer to speak with someone about your experiences, you may contact Abigail Stein, at astein9@partners.org.
Do you agree to the information above and want to proceed with the screening survey?
* must provide value
Yes
No
If you do not qualify for our study, are you interested in being contacted for other studies?
* must provide value
Yes
No
Now M-D-Y H:M
In order to identify your screening information when speaking with you, we require a name or identifier. First name or initials are acceptable.
* must provide value
E-mail Address
* must provide value
Phone Number
* must provide value
Do you have any contact preferences? (E.g., can only speak on the phone after 3PM, prefer e-mail, etc.)
* must provide value
How do you describe your gender?
* must provide value
Male
Female
Trans male/Trans man
Trans female/Trans woman
Genderqueer/Gender non-conforming
Different identity
What sex were you assigned at birth on your original birth certificate?
* must provide value
Male
Female
How would you describe your racial background?
* must provide value
First Nations (e.g., North American Indian, Métis, Inuit)
East Asian (e.g., Chinese, Japanese, Korean)
Southeast Asian (e.g., Cambodian, Indonesian, Vietnamese)
South Asian (e.g., East Indian, Pakistani, Sri Lankan)
Black (e.g., African, African Caribbean)
Central / South American
West/Central Asia and Middle East (e.g., Egyptian, Lebanese, Afghanistan, Iranian)
White (European)
Native Hawaiian or Pacific Islander
Interracial
Other
Are you Hispanic or Latino?
* must provide value
Yes
No
General Location
* must provide value
Greater Boston Area
Central/Western Massachusetts
New Hampshire
Rhode Island
Other (within USA)
Other (non-USA)
How did you hear about this study?
* must provide value
Craigslist
Flyers
McLean Website
BIDMC or CEDAR Website
Clinician/Therapist
Word of Mouth
Other
These questions will help us to evaluate whether or not participation in our research studies is appropriate for you. This survey is not intended to diagnose or treat any physical or mental health conditions.
You may refuse to answer any question. You may contact us by e-mail or phone if you prefer. If you are experiencing suicidal thoughts or any immediate health or safety concerns, please contact your personal physician, call 911, and/or visit an emergency department near you.
Have you ever had any injury or disorder impacting your central nervous system (such as epilepsy or serious head injury)?
Yes
No
Do you have any conditions that preclude MRI scanning, such as a pacemaker or other metal implants in your body?
Yes
No
Unsure
Have you ever had a head injury or lost consciousness for a period of time?
Yes
No
Have you had an ECT (electroconvulsive therapy) treatment in the past year?
Yes
No
This study involves MRI procedures and you will be required to be in the MRI scanner for an extended period of time. Do you consider yourself to be claustrophobic?
Yes
No
Do you have any non-removable body jewelry?
Yes
No
Do you have any tattoos on your head/neck or permanent eye-liner?
Yes
No
Have you ever had a mental health or psychiatric diagnosis?
Yes
No
Unsure
Have you ever been diagnosed with a disorder with psychotic symptoms (such as major depression with psychotic features, bipolar disorder, schizophrenia, substance-induced psychosis, etc.)?
Yes
No
Unsure
Have you ever received mental health treatment (e.g., therapy, psychiatric medication, hospitalization)?
Yes
No
Unsure
Do you currently take any psychiatric medications?
Yes
No
Unsure
Do you currently see a mental health care provider?
Yes
No
Unsure
Do you have any family history of psychosis-spectrum illnesses (including schizophrenia, schizotypal personality disorder, schizoaffective disorder, etc.)?
Yes
No
Unsure
These questions will help us to evaluate whether or not participation in our research studies is appropriate for you.
This survey is not intended to diagnose or treat any physical or mental health conditions.
You are not required to answer any question that you would prefer not to. You may contact us by e-mail or phone if you would prefer.
If you are experiencing suicidal thoughts or any immediate health or safety concerns, please contact your personal physician, call 911, and/or visit an emergency department near you.
I feel uninterested in the things I used to enjoy.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
I often seem to live through events exactly as they happened before (d
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
I sometimes smell or taste things that other people can't smell or taste.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
I often hear unusual sounds like banging, clicking, hissing, clapping or ringing in my ears.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
I have been confused at times whether something I experienced was real or imaginary.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
When I look at a person, or look at myself in a mirror, I have seen the face change right before my eyes.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
I get extremely anxious when meeting people for the first time.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
I have seen things that other people apparently can't see.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
My thoughts are sometimes so strong that I can almost hear them.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
I sometimes see special meanings in advertisements, shop windows, or in the way things are arranged around me.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
Sometimes I have felt that I'm not in control of my own ideas or thoughts.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
Sometimes I feel suddenly distracted by distant sounds that I am not normally aware of.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
I have heard things other people can't hear like voices of people whispering or talking.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
I often feel that others have it in for me.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
I have had the sense that some person or force is around me, even though I could not see anyone.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
I feel that parts of my body have changed in some way, or that parts of my body are working differently than before.
True
False
How much distress do you experience due to this?
None
Mild
Moderate
Severe
Some of my experiences mentioned above have started or worsened in the past year.
True
False
Unsure
N/A
I have experienced a decline in school or work performance in the past year.
True
False
Unsure
If you prefer to speak with someone directly regarding the survey questions or your responses, you can contact Abigail Stein at astein9@partners.org.
Your responses indicate that you are not interested in completing the full screening at this time.
If you prefer to speak with someone in-person regarding the survey questions or your responses, you can contact Abigail Stein at astein9@partners.org.