What is your name? First and Last Name
What is your date of birth? Today M-D-Y
Please indicate your sex Male
Female
Non-binary
Other
Prefer not to say
Male
Female
Non-binary
Other
Prefer not to say
How many children do you have who are currently living in your home? (Check all that apply - e.g., if you have three kids, you would check child #1, child #2, and child #3) No children
Child #1
Child #2
Child #3
Child #4
Child #5
Child #6
No children
Child #1
Child #2
Child #3
Child #4
Child #5
Child #6
Are any children adopted?
Child #1 - Name First and Last Name
What is ______ 's date of birth? Today M-D-Y
Please indicate ______ 's sex. Male
Female
Non-binary
Other
Prefer not to say
Male
Female
Non-binary
Other
Prefer not to say
______ 's Disability Status No treated or diagnosed developmental delays or disorders
Autism
Other disability
No treated or diagnosed developmental delays or disorders
Autism
Other disability
Other than an ASD diagnosis, has ______ been diagnosed with any other genetic syndrome? Yes
No
Please list which genetic syndrome ______ 's been diagnosed with.
Please list
Child #2 - Name First and Last Name
What is ______ 's date of birth? Today M-D-Y
Please indicate ______ 's sex. Male
Female
Non-binary
Other
Prefer not to say
Male
Female
Non-binary
Other
Prefer not to say
______ 's Disability Status No treated or diagnosed developmental delays or disorders
Autism
Other disability
No treated or diagnosed developmental delays or disorders
Autism
Other disability
Other than an ASD diagnosis, has ______ been diagnosed with any other genetic syndrome? Yes
No
Please list which genetic syndrome ______ 's been diagnosed with.
Please list
Child #3 - Name First and Last Name
What is ______ 's date of birth? Today M-D-Y
Please indicate ______ 's sex. Male
Female
Non-binary
Other
Prefer not to say
Male
Female
Non-binary
Other
Prefer not to say
______ 's Disability Status No treated or diagnosed developmental delays or disorders
Autism
Other disability
No treated or diagnosed developmental delays or disorders
Autism
Other disability
Other than an ASD diagnosis, has ______ been diagnosed with any other genetic syndrome? Yes
No
Please list which genetic syndrome ______ 's been diagnosed with.
Please list
Child #4 - Name First and Last Name
What is ______ 's date of birth? Today M-D-Y
Please indicate ______ 's sex. Male
Female
Non-binary
Other
Prefer not to say
Male
Female
Non-binary
Other
Prefer not to say
______ 's Disability Status No treated or diagnosed developmental delays or disorders
Autism
Other disability
No treated or diagnosed developmental delays or disorders
Autism
Other disability
Other than an ASD diagnosis, has ______ been diagnosed with any other genetic syndrome? Yes
No
Please list which genetic syndrome ______ 's been diagnosed with.
Please list
Child #5 - Name First and Last Name
What is ______ 's date of birth? Today M-D-Y
Please indicate ______ 's sex. Male
Female
Non-binary
Other
Prefer not to say
Male
Female
Non-binary
Other
Prefer not to say
______ 's Disability Status No treated or diagnosed developmental delays or disorders
Autism
Other disability
No treated or diagnosed developmental delays or disorders
Autism
Other disability
Other than an ASD diagnosis, has ______ been diagnosed with any other genetic syndrome? Yes
No
Please list which genetic syndrome ______ 's been diagnosed with.
Please list
Child #6 - Name First and Last Name
What is ______ 's date of birth? Today M-D-Y
Please indicate ______ 's sex. Male
Female
Non-binary
Other
Prefer not to say
Male
Female
Non-binary
Other
Prefer not to say
______ 's Disability Status No treated or diagnosed developmental delays or disorders
Autism
Other disability
No treated or diagnosed developmental delays or disorders
Autism
Other disability
Other than an ASD diagnosis, has ______ been diagnosed with any other genetic syndrome? Yes
No
Please list which genetic syndrome ______ 's been diagnosed with.
Please list
Are you a native speaker of English? Yes
No
Are you a fluent speaker in English? Yes
No
Do you have normal or corrected to normal hearing and vision? Yes
No
City and State
What is your phone number?
What is your preferred email?
What is your preferred method of contact? Phone
Email
Text
How did you find out about our study?
Someone from our team will be contacting you in 1-2 business days to follow up. If you have any questions in the meanwhile, please don't hesitate to contact us at scfamilystudy@gmail.com or by phone (803-576-7359). You can also visit our website at scfamilystudy.com .
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