Your Name*

Your Email*

Are you taking medication to treat your depression?  Yes No

Are you still depressed despite your medication?  Yes No

Are you experiencing side effects from your medication?  Yes No

Have you switched medications more than once due to side effects?  Yes No

Are depression symptoms interfering with your leisure activites or relationships with your family and friends?  Yes No

Are depression symptoms having an effect on your ability to earn a living?  Yes No