Join a Study

Parent/Guardian Name (First & Last)

Parent/Guardian - Phone Number

Parent/Guardian - Email Address

Preferred method of contact Preferred method of contact Email Phone

Preferred days/times to be contacted by phone, if needed

Is English regularly spoken in your home? Is English regularly spoken in your home? Yes No

NOTE: This study is examining the development of spoken English in young children with autism. Since you indicated that English is not regularly spoken in your home, your child is unfortunately not eligible to participate. Feel free call us if you have any questions about this.

Child's Name (First & Last)

Child's Date of Birth (MM/DD/YYYY)

Child's Sex Child's Sex Female Male

Has your child been diagnosed with Autism Spectrum Disorder OR been referred for a developmental evaluation due to suspected Autism OR screened positive on the Modified Checklist for Autism in Toddlers (M-CHAT)? Has your child been diagnosed with Autism Spectrum Disorder OR been referred for a developmental evaluation due to suspected Autism OR screened positive on the Modified Checklist for Autism in Toddlers (M-CHAT)? Yes No

Do you have concerns regarding your child's development? Do you have concerns regarding your child's development? Yes No

How did you hear about our study? (If applicable, please specify the name of the physician, therapy provider, community center, social media site, etc.)

Additional Comments / Questions