V3.0 Sooma

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lh_sourceshown for uat only
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eligibility_statusshown for uat only
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valid_stateshown for uat only
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What state do you live in?* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Are you between 22 and 70 years of age?* This field is required.
YESNO
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Have you been told by a medical health professional such as a psychiatrist or primary care provider that you have depression [also called as clinical depression or Major Depressive Disorder (MDD)]?* This field is required.Please try to be as accurate and honest as possible as your responses will be reviewed against your provided medical records.
YESNO
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Are you currently under the care of a psychiatrist or physician for your MDD?* This field is required.
YESNO
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Are you currently in a depressive episode?* This field is required.An episode is when you’re in a depressed mood or experiencing loss of interest or pleasure in daily activities, including the majority of symptoms such as problems with sleep, eating, energy, concentration, or self-worth.
YESNO
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Are you taking an antidepressant medication?* This field is required.Examples would be fluoxetine (Prozac), sertraline (Zoloft), duloxetine (Cymbalta), bupropion (Wellbutrin), trazadone, nortriptyline (Pamelor), and phenelzine (Nardil), etc.
YESNO
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Are you currently taking more than one antidepressant medication?* This field is required.Please try to be as accurate and honest as possible as your responses will be reviewed against your provided medical records.
YESNO
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Have you tried using 2 or more antidepressants for your current MDD episode?* This field is required.Please try to be as accurate and honest as possible as your responses will be reviewed against your provided medical records.
YESNO
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Have you been on the same dose of a single antidepressant medication without any recent changes in medication type or dosage?* This field is required.
YESNO
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If yes, how long have you been on this stable dose?* This field is required.
<1 week
2-4 weeks
≥5 weeks
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Would you be able and willing to continue taking your antidepressant medication at least through the first 10-week-phase of the study?* This field is required.
YESNO
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Do you have a smartphone or device running Android 7.0+ or iOS 13+ with access to a stable internet connection?* This field is required.
YESNO
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Are you willing to provide the names and contact information for two adults who live within a 60-minute drive of your residence?* This field is required.The study team would reach out to these contacts if we’re unable to reach you & in the event of an emergency.
YESNO
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Are you able to read, speak, and understand English well enough to complete study-related questionnaires and instructions?* This field is required.
YESNO
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Have you ever been diagnosed with mania or psychosis?* This field is required.
YESNO
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Are you currently receiving or have you previously received any brain stimulation treatments (such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), cranial electrotherapy stimulation (CES), transcranial direct current)?* This field is required.
YESNO
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Do you have sleep apnea?* This field is required.
YESNO
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If yes, are you using a sleep apnea treatment device to treat it?* This field is required.
YESNO
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Are you diagnosed with insomnia?* This field is required.
YESNO
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If yes, was the insomnia diagnosed prior to your depression diagnosis?* This field is required.
YESNO
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Do you have any neurological conditions, such as epilepsy, seizure history, or structural brain lesions?* This field is required.
YESNO
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Do you have any implanted medical devices (such as a pacemaker, insulin pump, or any brain implant)?* This field is required.
YESNO
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Has a medical health professional told you that you have a cognitive impairment (for example Dementia).* This field is required.
YESNO
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Has a medical health professional ever told you that you have any of the following: autism spectrum disorder, Obsessive Compulsive Disorder, or bipolar disorder. * This field is required.
YESNO
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Have you been diagnosed with and have active symptoms of PTSD, agoraphobia, anorexia or bulimia, panic or personality disorder?* This field is required.
YESNO
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Are you currently using, or have used during the past 4 weeks any benzodiazepines, z-drugs, or opioids.* This field is required.Examples would be benzodiazepines like Xanax, Valium, Halcion, Ativan and Klonopin, z-drugs like Ambien, Zimovane, Lunesta and Sonata, anti-convulsants like Gabapentin, and opioids like Vicodin, Norco, OxyContin, Percocet or Subutex.
YESNO
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Are you currently admitted or have ever been admitted to the hospital for depression?* This field is required.
YESNO
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Have you ever been diagnosed with a significant heart condition, such as myocardial infarction (heart attack), coronary artery disease, or heart failure?* This field is required.
YESNO
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The following question will ask you "Do you have a hairstyle or hair type, such as very thick hair or voluminous hairstyle, that would prevent wearing the treatment cap tightly and snugly on your head so that the electrodes are held close to your scalp/ skin" please use photo as a reference to answer this question. Select next to continue.
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Do you have a hairstyle or hair type, such as very thick hair or voluminous hairstyle (such as thick curls, dreadlocks, or thick braids), that would prevent wearing the treatment cap tightly and snugly on your head so that the electrodes are held close to your scalp/ skin?* This field is required.
YESNO
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Do you regularly wear wigs or hair pieces that cannot easily be removed or certain hair styles that could prevent contact between the electrodes and scalp? (e.g. toupees, weaves, any custom hair with adhesive or sewn pieces)* This field is required.
YESNO
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Do you have a history of previous suicide attempts, or hospitalization for suicidal behavior?* This field is required.Please try to be as accurate and honest as possible as your responses will be reviewed against your provided medical records.
YESNO
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Have you been diagnosed with an alcohol or substance use disorder within the past 12 months?* This field is required.
YESNO
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Have you smoked more than 100 cigarettes in your lifetime AND have you smoked every day within the past seven days?* This field is required.
YESNO
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Are you currently pregnant, breastfeeding, or planning to become pregnant during the study period?* This field is required.
YESNO
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Are you currently in another clinical trial or have been in the last 90 days?* This field is required.
YESNO
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Are you willing to provide Proof of your diagnosis and antidepressant prescription, or the information of the healthcare provider that has access to those records?* This field is required.
YESNO
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Are you willing and able to dedicate an hour to an hour and a half for the first study call?The call may be shorter if you have proof of ID available at the start of the call, have read the Informed Consent form you will receive via email and come to the call with any questions, and if you have your medical providers details and any related records ready for the call
YESNO
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Great, you're likely to be eligible for this study! Do you consent to the information entered here being stored by Lindus Health, subject to the terms of our Privacy Policy | Lindus Health, and being shared with the research team?* This field is required.Your consent is necessary in order to proceed.
YESNO
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Are you a resident of the state of California?* This field is required.
YESNO
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Please read this section and in the next section confirm if you wish to continue. We might ask you enter your name again later in this questionnaire for regulatory purposes.

CALIFORNIA EXPERIMENTAL SUBJECT’S BILL OF RIGHTS

Any person who is requested to consent to participate as a subject in a research study involving a medical experiment, or who is requested to consent on behalf of another has the right to:

Be informed of the nature and purpose of the experiment.

Be given an explanation of the procedures to be followed in the medical experiment, and any drug or device to be used.

Be given a description of any attendant discomforts and risks reasonably to be expected from the experiment, if applicable.

Be given an explanation of any benefits to the subject reasonably to be expected from the experiment, if applicable.

Be given a disclosure of any appropriate alternative procedures, drugs or devices that might be advantageous to the subject, and their relative risks and benefits.

Be informed of the avenues of medical treatment, if any, available to the subject after the experiment if complications should arise.

Be given an opportunity to ask any questions concerning the experiment or the procedures involved.

Be instructed that consent to participate in the medical experiment may be withdrawn at any time, and the subject may discontinue in the medical experiment without prejudice.

Be given a copy of a signed and dated written informed consent form when one is required.

Be given the opportunity to decide to consent or not to consent to a medical experiment without the intervention of any element of force, fraud, deceit, duress, coercion, or undue influence on the subject's decision.
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Signature* This field is required.Please draw your signature. This signature is to confirm you have read and understood the CALIFORNIA EXPERIMENTAL SUBJECT’S BILL OF RIGHTS
Clear
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PHQ-9 Consent - please review the study consent form and sign below.* This field is required.Please draw your signature. This signature is to confirm that you consent to answering the PHQ-9 form.
Clear
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What is your First name?* This field is required.Please enter your legal first name as shown on your government ID.
First Name
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What is your Last name?* This field is required.Please enter your legal last name as shown on your government ID.
Last Name
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Participant's SignaturePlease draw your signature. This is to confirm your agreement with the prescreening answers.
Clear
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What is your email address?* This field is required.Please double check this is the correct email address.
Email
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What is your mobile phone number?* This field is required.Your mobile number will only be shared with the research team to contact you about this study. Please double check this is the correct email number.
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What is your time zone?* This field is required.
US/Central
US/Eastern
US/Mountain
US/Pacific
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