Adolescent Autism Study

Join a Research Study Investigating a Potential Medication That May Improve Social Communications and Interactions for Adolescents with Autism Spectrum Disorder (ASD).

Clinical trial participants should be aged 12-17 and have symptoms and/or a diagnosis of Autism Spectrum Disorder (ASD).

Participation overview:

Participants will be between 12-17 and have symptoms and/or a diagnosis of Autism
The study will include 10 visits and 1 phone call over 25 weeks
Studies are supervised by specially trained doctors and medical staff
Study-related care and medication are provided at no cost (no insurance is needed)

Get Started

Complete this short questionnaire to determine if your child prequalifies. You’ll be contacted by study staff who can answer your questions before you decide to participate.

Fields marked with an * are required.

If you are under the age of 13 (or 16 if you are in California or in Europe), you may not directly enter any information and your legal parent or guardian must enter this information on your behalf. By filling out this form, you are confirming that you meet these requirements.

Do you consent to the collection and processing of your personal data, including information about your race and ethnicity (as applicable), and your health information, including symptoms, diagnoses, medications, and treatments and our sharing of this information for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested? You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed, or processed based on your consent. *

Yes

First Name of Child/Teen *

Last Name of Child/Teen *

Date of Birth MM/DD/YYYY of Child/Teen *

Zip Code or Postal Code of Child/Teen *

Has the Child/Teen been diagnosed (by a doctor) with Autism Spectrum Disorder (ASD)? *

Does the Child/Teen experience any symptoms of Autism Spectrum Disorder? *
Please note: Symptoms of ASD include difficulty communicating and interacting with others, marked delay in language and social development, intensely focused and/or repetitive behaviours, and trouble forming/understanding relationships.

Has the Child/Teen been diagnosed (by a clinician) with any other medical conditions? *
(For example: Epilepsy, seizures, hypertension, alcohol use or substance use disorder, coronary artery disease, stroke, transient ischemic attack, Prinzmetal’s angina, Wolff-Parkinson-White syndrome, galactose intolerance, basilar migraine, hemiplegic migraine, HIV, hepatitis B, hepatitis C, schizophrenia, bipolar disorder)
Please list here or write 'none'.

Is the Child/Teen taking any medications for their Autism or other health conditions? *
(For example: Risperidone (Risperdal®), Aripiprazole (Abilify®), Fluoxetine, Sertraline, Citalopram, Escitalopram, Paroxetine, Fluvoxamine, Desvenlafaxine (Khedezla®, Pristiq®), Duloxetine (Cymbalta®, Drizalma®, Irenka®), Levomilnacipran (Fetzima®), Amitriptyline, Amoxapine, Nortriptyline, Milnacipran (Savella®), Venlafaxine (Effexor®), Selegiline, Isocarboxazid, Phenelzine, Tanylcypromine, Bupropion (Wellbutrin®), Dihydroergotamine, Methysergide, Cimetidine)
Please list them here or write 'none'.

Please select the Child/Teen’s height from the dropdown below. *

How much does the Child/Teen weigh in Lbs (pounds)? *

Is the Child/Teen currently pregnant or breastfeeding? *

Which racial or ethnic group(s) does the Child/Teen identify with? Please select all that apply. *

American Indian or Alaskan Native

Asian

Black or African American

Hispanic/ Latino/ or Spanish

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Mediterranean (Greek/Italian/Portuguese/Spanish/etc)

Another race or ethnicity

I prefer not to answer

First Name of parent/ guardian to contact *

Last Name of parent/ guardian to contact *

Phone Number of parent/ guardian to contact *

Email of parent/ guardian to contact *

What is the best day/time to reach you via telephone? *

The information you are providing here will be processed in accordance with our Privacy Policy, which describes our data privacy practices, including how we share your information with our Research Partners and use your information to send you details about potential clinical trial opportunities. When you submit this information, you consent to AutoCruitment’s use of your data as described in our Privacy Policy. By providing your phone number and clicking “Submit” below, you consent to receive messages, including SMS/MMS text messages, sent by or on behalf of AutoCruitment, with information about research studies for which you may be eligible. By clicking Submit, you also agree to our SMS Terms. If you have any questions regarding the handling of the information you have provided to AutoCruitment, or if you would like to make any changes or withdraw your consent, please contact us at info@autocruitment.com.

ABOUT SSL CERTIFICATES

Privacy Policy
US State Law Privacy Notice