Research Interest Form Research Interest Form We are currently enrolling participants for several different ongoing research studies. Please complete the form below as thoroughly as possible. More information will allow us to provide the most appropriate study opportunities for you and your child. Please complete one form per individual. Thank you! Participant InformationParticipant Name First Middle Last Participant's GenderMaleFemaleParticipant Age (years)Date of Birth Date Format: MM slash DD slash YYYY What are the primary language(s) used in your home?Please specify which language your child is primarily exposed to.DEVELOPMENTAL DIAGNOSISCheck 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 languageVerbally FluentNon/Minimally VerbalInfantAny siblings with an Autism Spectrum Diagnosis?YesNoAny typically developing siblings?YesNoPRIMARY CONTACT INFORMATIONPreferred Contact Name First Last Preferred Method of ContactCheck all that apply. Email Phone Other Please specify other:(e.g., mailing address, etc.)Email AddressPhone NumberAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country What is your country of residenceUnited StatesHow did you hear about us? SPARK or Simon's Foundation IAN- Interactive Autism Network SPED Child & Teen Resource Fair Craigslist Facebook Boston Metro Printed recruitment materials (brochures, flyers, etc) Autism Awareness Event Family/Friend Referral Local University Local School Other Please specify other:Who referred you?Are you interested in being referred to affiliated/future studies?YesNoSend us a message! (optional)