Fields marked with an * are required.

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.

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

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Please fill out the below questionnaire on behalf of the child in your care so that they may be considered for the study.

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

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First Name of Potential Participant *

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Last Name of Potential Participant *

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

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Zip Code or Postal Code of Potential Participant *

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What is the Potential Participant’s sex assigned at birth? Please select one… Female Male Prefer not to say

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Does the Potential Participant have ADHD, or exhibit symptoms of ADHD (e.g., difficulty keeping attention, seeming to not listen when spoken to directly, not follow through when given directions, difficulty organizing tasks and activities, lose things necessary for tasks or activities, easily distracted by noise or stimuli, forgetful in daily activities)? *

Please select one… Yes – the Potential Participant has been diagnosed ADHD Yes – the Potential Participant has symptoms of ADHD No

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Has the Potential Participant been diagnosed by a doctor with any of the following conditions? *
Please select all that apply.
Please only include conditions that have been diagnosed by a doctor.

Tourette’s Disorder

Generalized Anxiety Disorder

Post-traumatic stress disorder

Bipolar Disorder

Autism Spectrum Disorder

Anorexia and/or Bulimia

Oppositional Defiant Disorder

Obsessive-Compulsive Disorder

Major Depression

None of the above

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Has the Potential Participant 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 Potential Participant taking any medications for ADHD or other health conditions? *
Please list them here or write 'none'.

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Please, select the Potential Participant’s height from the dropdown below * Please select one… 3'0" 3'1" 3'2" 3'3" 3'3" 3'5" 3'6" 3'7" 3'8" 3'9" 3'10" 3'11" 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"

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How much does the Potential Participant weigh in Lbs (pounds)? *

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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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