Affect Meth Recovery Study Questionnaire
Thank you for your interest in the Affect Therapeutics clinical trial. Affect delivers treatment services that are designed to help people stop using methamphetamine and other substances.We are looking for eligible individuals who wish to stop their meth use and who want to participate in a research study about the Affect treatment program. Program services are provided at no cost for research participants. Please complete this 5-minute questionnaire to determine if you're a good fit for our study.This information is used to ensure we have a diverse sample of participants. Only Affect will have access to this information. Your responses will be kept private and secure. The information will not be shared or used for any discriminatory purpose. If you are not selected for the study, all of your information will be purged from our database.
First name
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Last name
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Email address
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example@example.com
Phone Number
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Date of birth
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-
Month
-
Day
Year
Date Picker Icon
Please tell us your race and ethnicity (select those that apply):
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White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Other
What is your gender?
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Male (Including trans men)
Female (Including trans women)
Non-Binary
Gender Fluid
Questioning/Unsure
Other
What are your preferred pronouns?
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He/Him
She/Her
They/them
Do you consider yourself
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Asexual
Bisexual
Gay
Straight (Heterosexual)
Lesbian
Pansexual
Queer
Questioning / Unsure
Other
What's your highest level of education?
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Some High School
High School
Associate's Degree
Bachelor's Degree
Master's Degree
Doctorate Degree
Please provide an emergency contact, including their name, number, and your relationship to them.
Work / Life Situation
Current Employment Status?
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Full-time job (35+ hours)
Part-time job(s) (irregular hours)
Contractor / temp agency
Unemployed
What is your living situation for the next 2 months?
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Live in my own house or apartment
Live in the house or apartment of an immediate family member (parent or sibling)
Live in the house or apartment of another family member other than a parent or sibling
Live in the house or apartment of a friend
Live in a nursing home, long term care facility, or hospital
Currently homeless or will be within 2 months
"Couch Surfing" - bouncing from place to place, not sure where I will be from day to day/week to week
Other
Medical
Are you currently in an outpatient or inpatient treatment program for addiction? Please note, if you are already in another treatment program, this will disqualify you from joining.
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Yes
No
Do you have medical insurance? We strongly recommend participants have insurance that can cover any prescribed medications, if recommended by our doctors.
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Yes
No
Are you currently experiencing any of the following? (Our program may not be safe for people experiencing these conditions.)
Severe seizures
Stroke
Pregnancy
N/A - None of the Above
Are you currently experiencing any of the following? (Our program may not be safe for people with certain mental health conditions such as schizophrenia or suicidality).
Psychosis
Schizophrenia
Suicidality
N/A - None of the Above
Drug History
How do you typically take meth?
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Snort
Smoke
Inject
Other
How long have you been using meth?
Less than 6 months
6 months - 1 year
1-2 years
3-5 years
6-10 years
10+ years
N/A - never used stimulants
How often do you use meth?
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1 - 2 times a week
3 - 4 times a week
5 - 6 times a week
Everyday
Only on weekends but EVERY weekend
Only on weekends but NOT every weekend
Rate on a scale of 1-5: I have a problem with drugs and alcohol
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1
2
3
4
5
Rate on a scale of 1-5: I would like to change something about my alcohol or drug use.
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1
2
3
4
5
Rate on a scale of 1-5: I am already working on my problem with alcohol and drugs
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1
2
3
4
5
Technical Qualifier
Affect Therapeutics is a digitally based recovery program. All of your meetings will be through a smartphone app. As a result, in order to be successful in the program our participants need to be comfortable and familiar with smartphone apps.
Do you have a smartphone?
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Yes
No
What kind of smartphone do you have?
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iPhone
Android
What kind of data plan do you have?
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Unlimited data and texting
Limited data and texting
No data plan but I have access to Wifi
No data plan, no access to Wifi
Do you know how to install apps on your phone?
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Yes
No
Are you comfortable using text messaging?
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Yes
No
Do you know how to take a screenshot on your phone?
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Yes
No
Have you ever used zoom or another video meeting program such as Facetime?
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Yes
No
Program Qualifications
Can you access treatment for the full next 2 months (e.g. no expected jail time, inpatient stay)? Please note, answering no will result in disqualification from the program.
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Yes
No
Are you able to commit about 4 hours a week to this recovery program?
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Yes
No
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If there are any special instructions for delivery of mail (gate code, entry code, etc.) please let us know:
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Participating in the Affect program
Please check the times when you ARE available to attend meetings (e.g. when you don't have work, childcare).
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8am-9am
9am-10am
10am-11am
11am-12pm
12pm-1pm
1pm-2pm
2pm-3pm
3pm-4pm
4pm-5pm
6pm-7pm
7pm-8pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What days and times are you NOT AVAILABLE to have an appointment scheduled? Please consider your work schedule and all other commitments such as childcare.
Do you have any involvement currently with the criminal justice system or other legal obligations in the next two months that would prevent you from attending meetings?
Yes
No
Are there any circumstances in your life that would prevent you from attending meetings? If yes, what are they?
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You will be asked to attend virtual group therapy meetings. Can you commit to attending a 1-hour group meeting twice a week?
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Yes
No
Part of the program is completing short daily goals in a phone app for 10 minutes each day. Do you commit to completing these goals daily?
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Yes
No
Part of the program requires that you self-administer drug tests once a week. We ask our members to perform these tests for data analysis, and to hold themselves accountable during their recovery. Do you commit to participating in these tests?
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Yes
No
Study Inclusion and Exclusion Criteria
INCLUSION CRITERIA To be eligible to participate in the study, prospective participants must:1. Be 18 years of age or older;2. Have methamphetamine use disorder (MUD) or documented high-risk methamphetamine use history, confirmed by DSM-5 criteria for stimulant use disorder, methamphetamine type;3. Have stated interest in reducing and/or stopping methamphetamine use;4. Have and be able to use a smartphone and agree to download and use the Affect app as part of treatment and study-related procedures;5. Have a health insurance plan (or Medicaid) to ensure that participants have access to medical care if needed;6. Be English speaking and have reading capacity sufficient to understand explanations of study procedures and the informed consent to participate;7. Be an Arizona resident with a mailing address or P.O. Box8. Be able to freely give informed consent and be willing to electronically sign the digital informed consent to participate in the study;9. Be willing to comply with study procedures, including use of the Affect app consistent with the study protocol and therapeutic activities. EXCLUSION CRITERIAIndividuals will be precluded from enrolling in the study if they endorse (or if there is documentation of) any of following conditions. Already enrolled participants will be withdrawn from study participation upon emergence of any excluded condition (except pregnancy):1. Serious medical diagnoses (e.g., seizure, stroke, other chronic condition);2. Serious mental illness (e.g., schizophrenia, active suicidality);3. Moderate- to severe-level opioid use disorder;4. Pregnancy;5. Be concurrently receiving other behavioral or pharmacological services for treatment of MUD;7. Have pending legal action or other situation that could inhibit consistent participation in the study or in study activities.Additionally, if your application is not accepted or you choose not to participate after your questionnaire has been submitted, any information you provide will be destroyed.
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