Form completed for: --None--Myself My child Other

If other, please indicate for whom:

Name of Patient:

Age of Patient:

Research Contact Email:

Phone:

Latin American, Hispanic or Brazilian Ancestry: --None--Yes No

Level of Care: --None--Inpatient Residential Partial Intensive Outpatient Outpatient

Treatment Location for Research:--None--Brown Deer - Inpatient/Residential Building Brown Deer - Outpatient Building Oconomowoc - Cedar Ridge Residential OCD and Anxiety Recovery Center Oconomowoc - Kubly Residential Depression Recovery Center Oconomowoc - Delafield Residential Eating Disorder Recovery Center Oconomowoc - Herrington Residential Mental Health & Addiction Recovery Oconomowoc - Residential Trauma Recovery Center Oconomowoc - Silver Lake North Outpatient Center Oconomowoc - Silver Lake Outpatient Center West Allis - Lincoln Outpatient Center Other

Treatment Program for Research: --None--Depression Recovery Eating Disorder Recovery Mental Health and Addiction Recovery OCD and Anxiety Recovery Serious Persistent Mental Illness Recovery Trauma Recovery Other

Best days and times to meet: