Online Discussions on Mental Health Conditions Survey

Screening Survey

Thank you for your interest in our upcoming study. Please fill out the following preliminary questions below. Once completed, we will follow up with you shortly after regarding your eligibility in the project and if qualified, to discuss details and scheduling. If you do not qualify, we will email you at the end of the project thanking you for your time and asking if you would be interested in future projects that you may qualify for.

If you have any questions, please contact Alex at 847-533-4052 or email alex@lagripperesearch.com.

Thank you!

1.Please fill out the following contact information:

First Name

Last Name

City

State

ZIP/Postal Code

Email Address

Phone Number

2.Real Chemistry is an independent research organization serving the healthcare industry. Our role in this project is to collect information to better understand your experiences and shape how our client engages with patients.

This study is blinded and for our client’s research purposes only. The aggregated responses will be presented at a summary level, with no identification or attributions made to individuals. Please be aware that your personal information will not be released, sold, or otherwise shared with any third party, except when the individual is required by law to report an adverse event, in which case the sponsor will comply with data privacy regulations to protect that data. We will comply with all national laws protecting your personal data and with relevant guidelines including relevant national codes of practice.

If you qualify for this study, you will be asked to review and provide feedback on a digital support solution designed for people like yourself. Some features of this solution use artificial intelligence (AI) technology to provide personalized information and support. Your feedback will help us evaluate and improve the experience. This chat feature is AI-powered. Responses may be unreliable. Content is informational and not medical advice. Your healthcare provider is the best source for medical information.

Please provide your response to the following question:

Are you willing to continue with this research under these conditions?

Yes

3.To protect public health, regulatory authorities (e.g. the FDA, EMA) carefully review possible medication side effects and other adverse events. During this conversation, certain information that you may share about safety-related events, may be considered reportable and may be conveyed to the research sponsor. The research sponsor may wish to request further information from you, with your consent. However, you may still choose to remain anonymous.

Please select one of the below for how you would like to proceed in the event you mention a side effect or adverse event of one of the research sponsor’s products.

I would like to proceed and give permission for my contact details to be passed on to be passed on to the Pharmacovigilance (Global Drug Safety) department of the company if an adverse event is mentioned by me during the survey

I would like to proceed and and do not wish for my contact details to be passed on to the Pharmacovigilance (Global Drug Safety) department of the company if an adverse event is mentioned by me during the survey

I don’t want to proceed and would like to end the interview here