Long COVID Research Study Eligibility Form

This form is for eligibility screening purposes only. Information provided through this form is not stored on a HIPAA-compliant server. By submitting this form, you acknowledge and accept these terms.

First name

Last Initial

Email

Phone

Are you 18 years of age or older?

Do you have a current Long COVID diagnosis from a healthcare provider?

Are you currently receiving care from another provider for your Long COVID or related symptoms?

How would you describe the impact of your symptoms on your ability to work and manage daily life?

No change – I have symptoms, but they are not making daily life difficult.

Mild decline – I can still work and manage life, but with some difficulty.

Moderate decline – I have reduced work hours or need significant support with daily activities.

Severe decline – I am unable to work or manage daily activities independently.

Are you able to attend three in-person sessions at Zenbrio House in Eugene, Oregon?

Are you willing to commit to three paid sessions?

Are you willing to complete brief self-evaluations after each session?

Are you willing to participate in a confidential final interview?

Are you willing to have your session notes, health history, and outcomes included confidentially in the research study? (Your name and identifying information will not be included in the published results.)

By submitting this form, I confirm that the information I provided is true to the best of my knowledge, and I understand a team member will follow up by phone to confirm my eligibility and next steps.

Study Participant Eligibility Form

Thank you for your interest in participating in the Study!
Please complete this short form as the first step towards determining your eligibility.

Study Participant Eligibility Form

Thank you for your interest in participating in the Study! Please complete this short form as the first step towards determining your eligibility.

Thank you for your interest in participating in the Study!
Please complete this short form as the first step towards determining your eligibility.