Fill out the form below to see if you qualify.
First Name*
Last Name*
Email*
Phone Number*
Have you ever been diagnosed with Bipolar Disorder? YesNoNot sure
If yes, what type? ---Bipolar Disorder IBipolar Disorder IINot sure
Are you currently experiencing a depressive episode? yesno
If yes, how long has this CURRENT period of depression been going on? ---Less than 2 weeksAbout a monthA few monthsMore than 6 months
When was the last time you had a manic episode (period of hyperactivity lasting 3 or more days)? CurrentlyWithin the past monthA couple months ago4+ months ago
Have you ever attempted suicide? yesno
-If you answered yes, when was the last time you attempted suicide?
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