Fields marked with an * are required.

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 (“Health Data”) for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested, and disclosure to our Research Partners? 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. If you do not consent to the collection and use of your Health Data in this manner, we will not be able to provide you with our services or evaluate your eligibility to participate in the studies. *

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)? * Please select one… Yes – diagnosed with ASD No

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. Please select one... Yes – experiences any of the above symptoms of ASD No

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. * Please select one... 4'0" 4'1" 4'2" 4'3" 4'4" 4'5" 4'6" 4'7" 4'8" 4'9" 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8" 6'9" 6'10" 6'11"

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

Is the Child/Teen currently pregnant or breastfeeding? * Please select one... Yes No N/A- Male

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? *

Do you consent to receive recurring messages at the phone number you provided above, including SMS/MMS text messages, sent by or on behalf of AutoCruitment through the use of an autodialer or artificial intelligence with information about research studies for which you may be eligible? To opt out, reply “STOP”. For customer care or support, text “HELP”. Message and data rates may apply. Message frequency varies. By clicking “Yes”, you also agree to our SMS Terms and Privacy Policy. *

Yes No

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. If we become aware of information provided by a child under the age of 13 (or 16 if you are a California resident), we will delete such information.

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. 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.