Printable Study Flyer Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *How old are you? *Address *City, State and Zipcode ONLYWhen are the best days and time to contact you? *Do you consent to be contacted by the research team for this clinical trial? *YesNoIs the patients age between 10-17? *YesNoHas the patient been diagnosed with Bipolar disorder by a clinician? *YesNoDoes the patient experience depressed mood, loss of interest or pleasure, difficulty falling asleep, loss of energy and/or difficulty concentrating? *YesNoIs the patient pregnant, nursing or planning to become pregnant within the next 3 months? *YesNoWithin the past 2 years, have you had cancer other than basal cell carcinoma of the skin? *YesNoHave you participated in another clinical trial in the past 30 days? *YesNoAre you completing this form for yourself or someone else? *MyselfSomeone elseAre you the parent or guardian (or caregiver) of the individual with bipolar? *YesNoSubmit
