Center for Autism Research Excellence

Participant Information

Participant Name

First Middle Last

Participant's Gender

Participant Age (years)

Date of Birth

What are the primary language(s) used in your home?

Please specify which language your child is primarily exposed to.

Check all that apply

Undiagnosed infant
Autism Spectrum Disorders (Including Asperger's Syndrome and PDD-NOS)
Language based learning difficulties (Language disorder, Dyslexia, reading deficits, Specific language impairment)
Hearing Impairment
Neurological conditions (such as Fragile X, Neurofibromatosis, Cerebral Palsy, Tuberous Sclerosis, Brain Injury)
None
Other
Prefer not to disclose at this time

Please Specify Other:

What is your child's language level?

If your child has ASD please specify their level of spoken language

Any siblings with an Autism Spectrum Diagnosis?

Any typically developing siblings?

Preferred Contact Name

First Last

Preferred Method of Contact

Check all that apply.

Please specify other:

(e.g., mailing address, etc.)

Email Address

Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is your country of residence

How did you hear about us?

Please specify other:

Who referred you?

Are you interested in being referred to affiliated/future studies?

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