The University of Minnesota Psychiatry Department is committed to learning about mental health and discovering better treatments for conditions that affect our patients and others. Your participation in research is a way of giving back to the community and helping to improve the mental health of others in the future. The goal of all mental health research is to provide new knowledge that could ultimately benefit those living with these conditions.

By signing this authorization, you give your permission to include your name, contact information, medical record number, and if any, your or your child's mental health diagnosis and/or symptoms in the University of Minnesota Department of Psychiatry and Behavioral Sciences recruitment registry. This authorization allows research staff to use this information to let you know about studies for which you or your child may be eligible. This contact may include an in-person conversation, a phone call, email, and/or a letter.

Access to this registry will be limited to research staff in the University of Minnesota Psychiatry and Behavioral Sciences Department who have the permission of the University Institutional Review Board (the committee that reviews studies to protect the rights and safety of research participants).

We will not share your information with anyone outside of the University of Minnesota. Once your health information is disclosed under this authorization, there is a potential that it will be re-disclosed and no longer covered by this authorization. The research team and the University's Institutional Review Board are very careful to protect your privacy and limit the disclosure of identifying information about you.

You are only deciding to be included in the recruitment registry and to be contacted. You are not making any other commitment to be involved in research. Your decision not to be included in the recruitment registry will not affect any other treatment, payment, or enrollment in health plans or eligibility for benefits. This authorization does not expire. You can change your decision and withdraw this authorization at any time by filling out another form, or by writing to:

University Health Information Privacy and Compliance Office, 420 Delaware Street SE, Minneapolis, MN 55455

Sign below to authorize your inclusion in the research registry and to be contacted about research opportunities. A copy of this authorization will be made available upon request.

Research Consent to Contact Form: V2.5.19

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