Study Contact Form

Who are you completing this form for?
Your Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact
Potential Participant's Name
Potential Participant's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Which studies are you interested in? Check all that apply.
Has the participant been diagnosed with a mental health or behavioral health condition?
If you answered "Yes" to the previous question, what is the diagnosis or diagnoses?
Is the participant currently taking any medications for a mental health or behavioral health condition?
How did you hear about APG Research?
Is there anything else you'd like our research team to know? (optional)
Permission to Contact

By submitting this form, I authorize APG Research to contact me using the information provided to discuss research opportunities and potential eligibility. I understand that submitting this form does not enroll me or the participant in a research study and does not guarantee eligibility.
Check here if you agree.
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