|
National Mental Health Research Registry Sponsored
by Recover Resources A consumer owned/operated micro-enterprise Researchers from across
the U.S. are in great need of people with psychiatric conditions willing to participate in research studies. Most of these
studies involve surveys and/or interviews. Some occur in person while others are done over the telephone or the Internet.
Some studies pay participants, others do not. This registry has been established to help qualified researchers learn
about issues facing people with psychiatric disorders. Your participation in ANY study is voluntary. If you agree, and provide
the following information, your name and contact information will be made available only to legitimate researchers seeking
information that will help people with psychiatric disorders. By completing this form, you agree to have your information
shared with these researchers. You may have your information deleted from this registry at ANY time upon your request. Our
intent is to build a database researchers can use to recruit research subjects so the information gained will help many people
with psychiatric and/or substance abuse disorders. Arrangements for your participation in studies will be between you and
the researcher. You will not be paid for registering but you will receive an annual newsletter describing important research.
Your information will be kept confidential except when it is distributed to a researcher who requests it. Confidentiality
issues will then be between you and the researcher. Please print clearly! Name ________________________________________________________________
Street Address (including apartment number if applicable _____________________________________________________________________
City ______________________________ State ________ Zip __________________ E-mail address _________________________________________________________
1. What is your date of
birth? __________________________ _____________
2.
What is your gender? (Check
one) Male Female 3. How would you describe your race? (Check ALL that apply) White African American Pacific Islander Asian/Asian American
Latino Native American Other ______________________________ 4. What is your current marital status? (Check ONE) Single/Never Married Divorced/Annulled/Separated Widowed Married Living with partner
or significant other 5.
What is the highest level of education you have completed? (Check ONE) Did not attend school Up to 8th grade Some high school High school graduate GED
Post high school/not college (technical or vocational training) Bachelor's Degree or beyond (BA, BS, MS, MD,
PhD, etc.) 6. Has
a doctor given you a mental health diagnosis? If so, can you tell us what it is? (Please include all diagnoses you have been
given). _______________________________________________________________________________
7. Have you been
receiving services? If so, for how long? ______________ years 8. Are you currently working? Yes If yes, for how long? _____________________ No 9. Who do you live with? (Check ALL that apply) Alone (if this option is checked, no others can be checked) With family members
With spouse With children With significant other With unrelated others Other (Specify)_____________________________________________________________________
By submitting this form,
I understand my information may be shared with researchers and that I may be asked to participate in a study. I understand
I may voluntarily delete my information at any time from this registry and it is entirely my decision whether to engage in
any research study. Any study in which I participate is between myself and the researcher. The registry and Recover
Resources will not be involved in research projects and is not liable for any wrongdoing on the part of third parties. If
you have questions or concerns, please contact the following: National Mental Health Research Registry c/o Recover Resources 755 Alta Dale
Ada, MI 49301 Your completed form can be sent to the above address, e-mailed to: steve@recoverresources.com or faxed to: (781) 629-1633 Thank you!!!
|
