Today's date: Today M-D-Y
Manual Entry of Recruitment Fair Contact Yes
Name of Recruitment Fair:
Date of Recruitment Fair: Today M-D-Y
Contact Name:
Contact Phone Number:
Contact Email Address:
Relationship to Potential Participant: Self
Parent/Guardian
Other
Please Explain:
Participant Age:
Participant Diagnosis:
Notes or Additional Information:
I am completing this form for:* must provide value
Myself My child My patient
Full Name of Parent or Legal Guardian:
Contact Phone Number: Include Area Code
Contact E-mail Address:
Current Mailing Address:
What is the best way of contacting you? Call
Text
Email
How did you hear about us? Check all that apply. Doctor or Other Provider Referral
Resource Fair or Other In-Person Event
Social Media Advertisement or Posting
Email List-Serv
Fliers or Brochures
Newspaper Advertisement
Bus Shelter Advertisement
Google Search
Friend or Family Member
Other (please specify)
Other:
Full Name:
Last Name
Date of Birth: Today M-D-Y
Age View equation
Racial Background: American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Other
Please use this space to input your racial background:
Ethnicity: Hispanic or Latino
NOT Hispanic or Latino
Unknown / Not reported
Biological Sex: Male
Female
Preferred Pronouns: He/Him
She/Her
They/Them
Other
Please use this space to input your preferred pronouns:
Does your current gender identification match the sex you were assigned at birth? Yes
No
Please explain
Have you been diagnosed with any of the following? (please select all that apply) Autism
ADHD
Sensory Processing disorder
22Q Deletion Syndrome
Cystinosis
Multiple Sclerosis
Rett Syndrome
Schnizophrenia
Other
No Diagnosis
Suspected Autism Diagnosis (not currently diagnosed)
Please list other diagnosis:
Does anyone in your immediate family (siblings, parents, children) have any of the following Diagnoses? Autism
ADHD
Sensory Processing disorder
22Q Deletion Syndrome
Cystinosis
Multiple Sclerosis
Rett Syndrome
Schizophrenia
Other
No Diagnoses
Suspected Autism Diagnosis (not currently diagnosed)
Please list other diagnosis:
Are you currently taking any medications? Yes
No
Please list your current medication(s) and dosage(s):
Were you carried to full term, or born prematurely (born less than 37 weeks)? Full-term pregnancy
Premature birth (less than 37 weeks)
Unknown
Please specify your gestational age (at how many weeks were you born?):
Do you have a history of seizures? Yes
No
Do you have vision problems? Yes
No
Please explain vision problems:
Do you have hearing problems? Yes
No
Please explain hearing problems:
Child's Full Name:
Child's last name
Child's Date of Birth:* must provide value
Today M-D-Y
Child's Age View equation
Child's Racial Background: American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Other
Please indicate child's racial background:
Child's Ethnicity: Hispanic or Latino
NOT Hispanic or Latino
Unknown / Not Reported
Child's Biological Sex: Male
Female
Child's Preferred Pronouns: He/Him
She/Her
They/Them
Other
Please indicate child's preferred pronouns:
Does your child's current gender identity match their sex assigned at birth? Yes
No
Please explain
Has your child been diagnosed with any of the following? (please select all that apply) Autism
ADHD
Sensory Processing disorder
PDDNOS
22Q Deletion Syndrome
Cystinosis
Rett Syndrome
Schizophrenia
Other
No Diagnosis
Suspected Autism Diagnosis (not currently diagnosed)
Please list child's other diagnosis:
Does anyone in your child's immediate family (siblings, parents, children) have any of the following diagnoses? Autism
ADHD
Sensory Processing disorder
22Q Deletion Syndrome
Cystinosis
Multiple Sclerosis
Rett Syndrome
Schizophrenia
Other
No Diagnoses
Please list other diagnosis:
Is your child currently taking any medication? Yes
No
Please list your child's medication(s) and dosage(s):
Was your child carried to full term, or born prematurely? Full-term pregnancy
Premature birth
At approximately how many weeks was your child born (full term is considered to be 37-42 weeks)?
Has your child ever completed genetic testing? Yes
No
Has your child ever been diagnosed with any of the following genetic conditions? (please select all that apply) PTEN mutation
Fragile X syndrome
ADNP Syndrome
SHANK3 Mutation
Tuberous Sclerosis
Other
No Genetic Diagnosis
Please list other genetic conditions and/or findings:
Does your child have hearing problems? Yes
No
Please explain hearing problems:
Does your child have a history of seizures? Yes
No
Does your child have vision problems? Yes
No
Please explain vision problems:
Does your child receive any interventions, outside of the school setting? Yes
No
What kind of intervention is your child receiving? (please select all that apply) ABA
Sensory Integration Therapy
Speech
Physical Therapy
Social Group
Other
Other therapy:
Approximately how many hours of ABA is your child receiving each week, outside the school setting?
Approximately how many hours of Sensory Integration therapy is your child receiving each week, outside the school setting?
Approximately how many hours of Speech therapy is your child receiving each week, outside the school setting?
Approximately how many hours of Physical therapy is your child receiving each week, outside the school setting?
Approximately how many hours of Social group is your child attending each week, outside the school setting?
By clicking here, you attest that all information you provided in this form is accurate to the best of your knowledge* must provide value
I agree
Please click the link below for a PDF of Einstein's IRB letter of approval for the Human Clinical Phenotyping Core (HCP) Please click the link below for a PDF of the HCP consent form Please click the link below for a PDF of the HCP consent form I consent to the researchers reviewing my medical records for purposes of this research registry, and to determine eligibility for future studies (optional)* must provide value
I consent
I DO NOT consent
All information is kept within HIPAA compliance, and is not shared with outside parties
By clicking here, you consent to the Human Clinical Phenotyping Core at Albert Einstein College of Medicine storing this screener, so the study team can contact you about studies you may qualify for. * must provide value
I consent
All information is kept within HIPAA compliance, and is not shared with outside parties
Provider Name:
Provider Email:
Provider Affiliation(s): Montefiore Healthy Steps or Behavioral Health Integration Program (BHIP)
Montefiore Children's Evaluation and Rehabilitation Center (CERC)
Montefiore RETT Syndrome Center
Montefiore-Einstein Regional Center for 22q Deletion Syndrome
Montefiore School Health Program
Other Program or Center at Montefiore Medical Center
Jacobi Medical Center
Other (please specify)
Montefiore Primary Care
Please list other affiliation(s):
How did you hear about us? Presentation from Study Team at the CNL
Colleague(s) and/or Other Provider(s)
Resource Fair or Other In-Person Event
Social Media Advertisement or Posting
Email List-Serv
Fliers or Brochures
Newspaper Advertisement
Bus Shelter Advertisement
Google Search
Friend(s) or Family Member(s)
Other (please specify)
Please specify:
By clicking here, you affirm that you have obtained verbal or written permission from your patient (if 18+ years old) or their parent/legal guardian (if < 18 years old) to share their contact information with the study team so they can be contacted about study participation. * must provide value
I have received the appropriate permissions to share my patient's information
We are currently accepting referrals for several research studies at the CNL (both clinical and control participants). Please use the links below to learn more about these projects and determine if your patient may qualify to participate.
Autism Genetics & Human Diversity (ages 3+); Click here to visit study website Brain Function & Communication in Autism (ages 8-12); Click here to visit study website Predictive Processing in Autism (ages 17-29); Click here to view our brochure Cognitive Function in Cystinosis & CKD; Click here to view our fliers Which study did you discuss with your patient?
Autism Genetics & Human Diversity (ages 3+)
Brain Function & Communication in Autism (ages 8-12)
When did you discuss study participation with this patient? Today M-D-Y
Patient Name:
Patient date of birth: Today M-D-Y
Diagnostic Status: Patient has Autism Spectrum Disorder
Patient is suspected of having Autism Spectrum Disorder
Patient has a sibling with Autism Spectrum Disorder
Patient has no confirmed or suspected diagnoses
Other
Specify other diagnostic category:
Parent or Guardian Name (if patient under 18 years old):
Preferred Phone Number:
Preferred E-mail Address:
Working...