Beacon Interest — Mental Health

Who is completing this form?

Myself Parent/legal guardian Spouse/partner Other caregiver

Full name

Email address

Mobile phone number

US format; used for SMS + call

Preferred contact method

Phone call Text message Email

Best time to reach you

Morning Afternoon Evening Anytime

Date of birth

Derives age for eligibility.

Sex assigned at birth

Female Male Intersex Prefer not to say

Gender identity (optional)

Woman Man Non-binary Prefer to self-describe Prefer not to say

City and state

ZIP / postal code

Primary geo-match signal.

How far would you travel for a study?

Under 10 mi 10–25 mi 25–50 mi 50+ mi Remote/at-home only

Preferred language

English Spanish Other

Preferred language (other)

I agree to be contacted about future research opportunities that may fit me.

I agree to be contacted about future research opportunities.

I have read the privacy notice and understand my information is stored securely and I can opt out anytime.

I have read and accept the privacy notice.

Which of these apply to you? Choose any.

Other mental-health condition (please specify)

Have you been diagnosed by a healthcare professional?

Yes No Not sure

About how long have you been managing this?

Under 6 months 6–12 months 1–3 years 3+ years

Are you currently in treatment? Choose any.

Medication Therapy/counseling Both Not currently

Current psychiatric medications (if any)

Psychiatric hospitalization in the past 12 months?

Yes No

Overall, how much do symptoms affect your daily life now?

A little Somewhat Quite a bit A great deal

Are you currently in crisis or having thoughts of harming yourself?

Yes No

If you are in crisis, help is available now

If you are in crisis or thinking about harming yourself, help is available right now.

Call or text 988 — the Suicide & Crisis Lifeline (24/7) — or call 911 if you are in immediate danger.

This screening does not provide emergency help. CLINICAL/LEGAL: confirm final crisis wording and routing before launch.

Over the last 2 weeks, little interest or pleasure in doing things?

Not at all Several days More than half the days Nearly every day

Over the last 2 weeks, feeling down, depressed, or hopeless?

Not at all Several days More than half the days Nearly every day

How many depressive episodes have you had?

First episode 2–3 4+ Not sure

Have you tried 2 or more antidepressants without enough relief?

Yes No Not sure

Type of experience related to your PTSD (optional)

Combat/military Accident or injury Physical or sexual assault Sudden loss Other Prefer not to say

About how long ago did the experience occur?

Under 1 year 1–5 years 5–10 years 10+ years

Bipolar type

Bipolar I Bipolar II Not sure

How would you describe your mood right now?

Depressed Elevated/manic Stable Mixed

[OCD] Most prominent symptom type

Contamination Checking Intrusive thoughts Symmetry/order Other

[ADHD] When were you diagnosed?

As a child As an adult Not formally diagnosed

[ADHD] Presentation

Inattentive Hyperactive/impulsive Combined Not sure