Fields marked with an * are required.

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

Who are you interested in this research 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 or other tic 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… 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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If female, is the potential participant currently pregnant or breastfeeding? Please select one... Yes No N/A - Male

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Would you like to be contacted about your teen’s participation in the Castle Study?*

Yes

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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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The information you are providing here will only be used to match your teen to a clinical research study in the potential participant’s area and contact you to see if your teen would like to participate. Please note the information you enter will be kept private, except when ordered by law, and only accessible to our Clinical Research Partners and affiliates and applicable regulatory agencies. If you have any questions regarding the handling of the information you have provided to autocruitment.com, or if you would like to make any changes, please contact us at info@autocruitment.com.

I was given the opportunity to review the AutoCruitment Privacy Policy. READ THE AUTOCRUITMENT PRIVACY POLICY *

Yes

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