BCFS00617-CUAnschutz-Stoddard-AdolescentMood [Screening Form

Screening Form

Please complete the screening form below

First Name

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Last Name

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Phone Number

Email Address

Teen First Name

Teen Last Name

What city do you live in?

What state do you live in?

Is your teen between the ages of 13 and 17 (inclusive)?

Yes

No

Does your teen have any conditions or factors that would make it unsafe for him/her to undergo an MRI scan? This could include non-removable metal objects in the body (such as braces)

Yes

No

Are you and your teen willing and able to come in for one in person study visit on campus?

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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Screening Form

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