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.

Who are you interested in this study for? * Please select one... Myself My Child The Child I Care For Other

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Potential Participant Information

Child’s First Name *

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Child’s Last Name *

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Child’s Date of Birth MM/DD/YYYY *

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Child’s Zip Code or Postal Code *

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Is the child or adolescent Male or Female? Please select one... Female Male Prefer not to say

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Has the child or adolescent been diagnosed with Schizophrenia? * Please select one... Yes – the child or adolescent has Schizophrenia No Unsure

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Does the child or adolescent experience any of the following symptoms?
Please select all that apply

Hearing things that other people cannot hear

Seeing things that other people cannot see

Feeling or smelling things that other people cannot feel or smell

Lack of emotional expression

Odd or unusual thoughts/beliefs that other people do not understand

Believing that people are spying on or plotting against them

Speaking in a way that is difficult for others to understand

Withdrawing from friends or family

An untidy or unkempt appearance

Unpredictable or abnormal behavior

None of the above

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Has the child or adolescent been diagnosed (by a doctor) with any other medical conditions? *
Please list here or write 'none'
Please only include conditions which have been diagnosed by a doctor.

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Is the child or adolescent currently taking (or ever taken) an antipsychotic? *
Examples include: aripiprazole (Abilify Maintena®, Aristada®, and Abilify®), asenapine (Saphris®), olanzapine (Zyprexa Relprevv®, Zyprexa Zydis®, and Zyprexa®), paliperidone (Invega Sustenna®, Invega Trinza®, and Invega®), quetiapine (Seroquel XR® and Seroquel®), and risperidone (Risperdal M-TAB®, Risperdal Consta®, and Risperdal®). Please select one... Yes No Unsure

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Is the child or adolescent taking any medications for other health conditions? *
Please list them here or write 'none'.

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If female, is the child or adolescent currently pregnant or breastfeeding? Please select one... Yes No N/A - Male

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First Name of caregiver/parent to contact *

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Last Name of caregiver/parent to contact *

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Phone Number of caregiver/parent to contact *

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Email of caregiver/parent to contact

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

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Would you like to be contacted about taking part in a research study that the child or adolescent may qualify for? *

Yes

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