Thank you for showing interest in being a participant in our 'Psilocybin in patients with fibromyalgia: EEG-measured brain biomarkers of action' study at Imperial College London. 

Please read the summary sheet below for information on the study and check the inclusion and exclusion criteria below. Please note that this list of criteria is not exhaustive, but checking these carefully will help us with the screening process. Please also note that not everyone who meets these criteria will be able to participate in this study. We will nevertheless endeavour to contact everyone who completes the form below. 

If you believe you are eligible to take part in the study please provide your contact information, which we may then use to contact you to arrange a remote screening. 

Please only complete this self-referral form to register interest in the 'Psilocybin in patients with fibromyalgia: EEG-measured brain biomarkers of action' study.

 If you have any questions, please contact the study team on psilopain.trial@imperial.ac.uk.
Please carefully read the following document. 
PIS V3 1
 
PIS V3 2
 
PIS V3 In/Exclusion Criteria
Please confirm you have read the above summary sheet
Please confirm that, to the best of your knowledge, you meet the inclusion criteria.
Please confirm that, to the best of your knowledge, you do not meet any of the exclusion criteria.
I understand that completing this form does not guarantee that I will undergo screening or will be a participant in the study. I understand that eligibility will only be confirmed once the screening process is complete and that only a small number of those who are screened will be able to participate.
Please confirm that you meet the following inclusion criteria
We will now ask you some questions about your fibromyalgia. 

The first question will refer to the areas shaded in dark blue in this diagram:
Screenshot 2022 03 09 at 15.15.57
Please identify the areas where you felt pain over the past week. Please select all that apply.

Using a scale of 0 to 3, please indicate your level of symptom severity over the past week in each of the 3 symptom categories. Please only choose 1 level of severity for each category.
Which of the following somatic symptoms have you experienced over the past week? Please select all that apply.