* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

Have you taken antidepressants?Yes
No

Name(s) of all antidepressants taken:

Date you started taking this drug:

Date you stopped taking this drug:

What condition was this medication prescribed to treat?

Age of patient when antidepressant(s) prescribed:

Please describe your case:

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