RCBM Clinical Trials

Please complete this form if you are interested in finding out if you qualify for any of our current research studies.
One of our study coordinators will contact you at their soonest convenience.

Patient's First Name:*
*
*
*
*
Presenting concern (reason for research interest)
Please list ALL mental health diagnoses:
*
Gender:
M        F
Is the patient currently in therapy?
Yes    
No
Is the patient currently taking any medication (including herbal remedies or vitamins)?
Yes     No
If Yes, please list ALL medication:
Does the patient have a history of seizures/epilepsy?
Yes     No
Does the patient have a history of heart problems?
Yes     No
Has the patient previously participated in any research studies?
Yes     No
If yes, when?