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Screening Form
Please complete the screening form below
First Name
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Last Name
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Phone Number
Email Address
Gender
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Male
Female
Date of Birth
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Teen’s First Name
Teen’s Last Name
Teen’s age
What city does your teen live in?
What state does your teen live in?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Select
What category best describes your teen?
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
Please select the option that accurately describes your teen’s situation:
My teen has been diagnosed with autism.
I strongly suspect that my teen may have autism.
There is no diagnosis of autism for my teen, and I have no reason to suspect that they have autism.
Is your teen willing to undergo an MRI?
Yes
No
You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.
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BCFS00606