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Screening Form
Please complete the screening form below and our team will be in touch. Thank you!
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First Name
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Last Name
Phone Number
Email Address
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Gender
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Other
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Date of Birth
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What city do you live in?
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What state do you live in?
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Select all of the following that best describes you:
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish origin
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Which of the following neurodevelopmental conditions have you been diagnosed with?
ADHD
Autism
Oppositional defiant disorder (ODD)
Conduct disorder
Tourette syndrome
Intellectual disability
Cerebral palsy
Other
None of the above
Have you ever experienced any gastrointestinal (GI) problems, such as nausea, vomiting, diarrhea, constipation, or abdominal pain?
Yes
No
Do you speak English or Spanish?
Yes
No
Are you able to provide your own consent without requiring a legal guardian?
Yes
No
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BCFS001403
