Your Name*

Your Email*

Your Phone Number*

Have you been diagnosed with MDD? YesNo

Have you seen a therapist for your symptoms of Depression? YesNo

Have you taken medication for your symptoms of Depression? YesNo

Are you still depressed despite your medication/in therapy? YesNo

Have you experienced negative side effects from antidepressant medication? YesNo

Have you changed medications more than once due to ineffectiveness or negative side effects? YesNo

Are depression symptoms having an effect on your ability to earn a living, enjoy leisure activities, or spend time with family and friends? YesNo