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

Screening Form

Please complete the screening form below

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First Name

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Last Name

Phone Number

Email Address

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Gender

Male

Female

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

What is your sexual orientation?

Heterosexual (Straight)

Gay

Lesbian

Bisexual

Pansexual

Asexual

Queer

Questioning/Uncertain

Other

Are you currently enrolled in high school?

Yes

No

Which of the following substances do you regularly use?

Nicotine (e.g., cigarettes, vaping)

Cannabis

Stimulants (e.g., cocaine, methamphetamine, ecstasy)

Depressants (e.g., tranquilizers, benzodiazepines)

Opioids (e.g., heroin, prescription painkillers)

Hallucinogens (e.g., LSD, psilocybin)

Inhalants (e.g., solvents, aerosols)

Other

None of the above

Have you had a significant head injury or loss of consciousness that lasted more than 5 minutes?

Yes

No

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

Yes

No

Please select your pronouns

She/her

He/him

They/them

Other (Please Specify)

Please specify your pronouns:

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