Autism Study

Do you or a child in your care have Autism?

Would you like to take part in a Clinical Research study for an oral (taken by mouth) investigational drug for children with Autism at no cost to you?

Sign up and we will notify you of clinical trials in your area that need children 5-17 years old diagnosed with Autism.

Participants who complete the study may be compensated.

Participants will receive all study-related care from a dedicated medical team at no cost.

What happens if I sign up?

You may be eligible for an Autism clinical research study, also known as a clinical trial in your area. Someone from the study team or study site conducting the trial will contact you to explain more about this research study before you make your decision about participating.

Sign Up

Fields marked with an * are required.

If you are under the age of 13 (or 16 if you are in California), 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. If you are filling out the form on behalf of your child, please answer according to their information. Please also be aware that you may be required to be present and willing to sign permission to allow the minor to participate in the interview.

Who are you interested in this study for? *

First Name of Potential Participant *

Last Name of Potential Participant *

Date of Birth MM/DD/YYYY of Potential Participant *

Zip Code of Potential Participant *

Is the Potential Participant Male or Female?

Have you – or the Potential Participant (if filling this out for them) – been diagnosed (by a doctor) with Autism? *

Does the child experience any of the following symptoms? *
Please select all that apply.

Repetitive stereotypical behavior such as hand clapping or finger mannerisms

Notably high levels of irritability

Verbal and physical aggression

Self-injury and/or property destruction

None of the above

Do you – or the Potential Participant (if filling this out for them) – experience symptoms of irritability, distress or frustration? *

Is your child non-verbal? *

(Non-verbal in autism refers to the child using varying degrees of speech to communicate. There are differing levels of non-verbal, from slightly non-verbal where the child can still use speech, to completely non-verbal where the child cannot communicate verbally at all.)

To what degree is the child non-verbal? *

Are you – or the Potential Participant (if filling this out for them) – interested in trying an investigational drug for autism? *

Have you – or the Potential Participant (if filling this out for them) – been diagnosed (by a doctor) with any other medical conditions? *
(For example: Bipolar disorder, Schizophrenia, Schizoaffective disorder, Schizophreniform disorder, Brief psychotic disorder).

Are you – or the Potential Participant (if filling this out for them) – taking any medications for your/their Autism or other health conditions? *
Please list here or write 'none'.

If female, are you – or the Potential Participant (if filling this out for them) – currently pregnant or breastfeeding? *

Are you – or the Potential Participant (if filling this out for them) – currently participating in a clinical trial for an investigational drug or device? *

First Name of caregiver/parent to contact *

Last Name of caregiver/parent to contact *

Phone Number of caregiver/parent to contact *

Email of caregiver/parent to contact

What is the best day/time to reach you via telephone (we know you are busy)? *

Do you consent to the collection and processing of your personal data (including information about your health, race and ethnicity (as applicable); including disclosure to our Research Partners) for the purpose of recruitment into clinical research studies? *

Yes

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.