Fill out the form below to see if you qualify.
First Name*
Last Name*
Email*
Phone Number*
Have you felt down or depressed nearly every day for the past 2 weeks? yesno
When did this current episode begin or get worse?
Are you not able to enjoy the things you used to enjoy most of the time? yesno
- If yes, can you give an example?
How’s your appetite? DecreasedNormalIncreased
Do you have trouble sleeping? yesno
Do you ever sleep longer than normal (10+ hours)? yesno
Do you feel tired or without energy almost every day? yesno
Do you feel worthless or guilty almost every day? yesno
Do you consider hurting yourself, feel suicidal, or wish you were dead? yesno
Have you had any suicide attempts in the past? yesno
- If yes, when did this occur?
Have you ever had any periods of time where you felt so happy or hyper that you felt like you were on top of the world or could stay awake for several days? yesno
- If yes, how many days did this last? 1-22-33-45+
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