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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 First Name
Teen Last Name
Teen Date of Birth
What city do you live in?
What state do you 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
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
What is your teen’s age?
13 or younger
14-17
Are you willing to participate in this research study along with your teen?
Yes
No
Has your teen been diagnosed with Bipolar Type I or II?
Yes
No
Is your teen currently in remission (no mood symptoms for the last 8 weeks)?
Yes
No
Does your teen (or do you) own a smartphone?
Yes
No
Has your teen been diagnosed with Autism Spectrum Disorder?
Yes
No
Does your teen have an intellectual disability?
Yes
No
Has your teen been diagnosed with Schizophrenia?
Yes
No
Does your teen have any serious medical conditions that would impact his/her ability to participate in the research study?
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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