(First Party) BCFS00570-UPitt-Eckstrand-AdolescentEmotion [Parent Screening Form] -

Screening Form

Please complete the screening form below

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Parent's First Name

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Parent's Last Name

Parent's Phone Number

Parent's Email Address

Child's First Name

Child's Last Name

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Child's Gender

Male

Female

Other

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Child's 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 your child:

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

What is your child's sexual orientation?

Heterosexual (Straight)

Gay

Lesbian

Bisexual

Pansexual

Asexual

Queer

Questioning/Uncertain

Other

Is your child currently enrolled in high school?

Yes

No

Has your child had a significant head injury or loss of consciousness that lasted more than 5 minutes?

Yes

No

Does your child have any limitations that would prevent them from safely undergoing an MRI scan, such as having non-removable metal objects in their body (implants, pacemakers, etc.) or experiencing claustrophobia?

Yes

No

Please select your child's pronouns

She/her

He/him

They/them

Other (Please Specify)

Please specify your child's pronouns:

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