Screening Form
Please complete the screening form below and our team will be in touch. Thank you!
You are being asked to voluntarily give us some information to see if you might qualify to be enrolled in a research study. This study involves taking medication and drinking alcohol during study visits. If you agree to be screened for eligibility, we will ask you to provide contact information and answer questions about your demographics, alcohol consumption and treatment history, and availability.

If your responses to the screening questionnaire are satisfactory, a member of the research team will reach out to you using the contact information you have provided and conduct a complete telephone screening to determine your eligibility for the study.

All responses to the screening questionnaire will be stored in a password-protected, secure computer system.