UPitt-VaughnCoaxum-AdolescentDepression-Parents

Screening Form

Please complete the screening form below and a member of the research team at the University of Pittsburgh will be in touch. Thank you!

Screening Form

Please complete the screening form below and our team will be in touch. Thank you!

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First Name

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Last Name

Phone Number

Email Address

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Gender

Male

Female

Hidden

Date of Birth

Child First Name

Child Last Name

Child Date of Birth

What is the best method to contact you?

Call

Text

What is the best time to contact you?

Early Morning (8AM-10AM)

Late Morning (10AM-12PM)

Early Afternoon (12PM-3PM)

Late Afternoon (3PM-5PM)

Evening (5PM-7PM)

Can we text you?

Yes

What city do you live in?

What state do you live in?

What category best describes your child?

American Indian or Alaska Native

Asian

Black or African American

Hispanic, Latino, or Spanish origin

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Is your child between the ages of 12 and 15 years old?

Yes

Does your child frequently feel sad, depressed, irritable or withdrawn?

Yes

How long has your child been experiencing these feelings?

Has your child been diagnosed with autism spectrum disorder?

Yes

Has your child been diagnosed with attention deficit hyperactivity disorder?

Yes

Has your child ever been diagnosed with a chronic medical condition?

Yes

You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.

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