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Anxiety and GAD Survey Form
I am completing this form to apply for acceptance into the Anxiety and GAD release research study. All the information provided in this form is confidential and will be kept private between me and the designated study researcher. I also acknowledge that I must read and agree to an Informed Consent Form, which will be sent to me by email after my current survey submission is reviewed.
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Email
*
Record my email address with my response
Find the elephant in your mind and let it run free, so you can enjoy life!
Participant Code (to be provided after enrolling in the research study):
Your answer
First Name (Optionally, add your call name):
*
Your answer
Last Name:
*
Your answer
Gender:
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Female
Male
Prefer not to say
Date of Birth:
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MM
/
DD
/
YYYY
Ethnicity:
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White/Caucasian
Black/African Descent
Hispanic/Latino
Indigenous/Native/First People
Asian/Filipino/Indian
Polynesian/Aboriginal
Other:
Religion/Spiritual (Optional):
Your answer
Address (Enter your standard postal format):
Your answer
Phone number (used for everyday interactions):
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Your answer
Since when have you noticed anxiety? (Mo/Year, Event)
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Your answer
Describe how anxiety has impacted changes in your life.
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Your answer
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