GEODE Screener Page

Consent*

Before completing this form we need your consent to gather information about you and your adolescent. This information will be used to determine whether they are eligible to participate in this study. The purpose of this study is to learn more about how teenagers with and without autism use visual cues to make decisions in the context of an adventure game. Participation is completely voluntary. You will be asked to provide information about you and your teen's health/developmental history, language, and behavior. You do not have to answer any questions you don't want to and you can stop filling out this form at any point. Any information you provide will be kept confidential. Do you consent to continue with this form?

Yes, I consent
No, I do not consent
No, I prefer to complete an eligibility interview over the phone

Parent/Guardian Information

Today's Date*

Parent's Name*

First Last

How may we contact you?*

Phone call
Text message
Email

Select all that apply

Please select your preferred method of contact*

Phone call
Text message
Email

Preferred phone number:*

Preferred email address:*

Your Relationship to the Participant (Your Teen)*

Biological Mother
Biological Father
Non-Biological Mother
Non-Biological Father

Additional Contact Name

First Last

Alternative Phone Number

Alternative Email

Teen 1 Information

Teen 1: Name (Participant)*

First Last

Teen 1: Sex*

Male
Female
Prefer not to answer

Teen 1: Date of Birth*

Teen 1: Age*

(years, month)

Teen 1: Does your teen have an official diagnosis of ASD (including PDD-NOS, Autism or Asperger's, or Social Communication Disorder)?*

Yes
No

Teen 1: Has your teen received any interventions?*

Yes
No

Teen 1: Has your teen received at least 6 months of intervention?*

Yes
No

Teen 1: How does your teen most often communicate?*

Speech sounds and gestures
AAC (Augmentative/Communication Device) or PECS (Picture Exchange Communication System)
Single word approximations and gestures
Single words
2-3 word phrases
Full sentences

Select all that apply

Teen 1: Does your teen live in the United States?*

Yes
No

Teen 1: If your teen does not live in the United States, what country do they live in?*

Teen 1: Are you comfortable with us recording your teenager over zoom? (for data analysis we will need to record the interviews and activities. Please note, when we analyze and save data, your name will always be kept separate from your data)*

Yes
No

Teen 2 Information (Only if applicable)

Teen 2: Name (Participant)

First Last

Teen 2: Sex

Male
Female
Prefer not to answer

Teen 2: Date of Birth

Teen 2: Age

(years, month)

Teen 2: Does your teen have an official diagnosis of ASD (including PDD-NOS, Autism or Asperger's, or Social Communication Disorder)?

Yes
No

Teen 2: Has your teen received any interventions?

Yes
No

Teen 2: Has your teen received at least 6 months of intervention?

Yes
No

Teen 2: How does your teen most often communicate?

Speech sounds and gestures
AAC (Augmentative/Communication Device) or PECS (Picture Exchange Communication System)
Single word approximations and gestures
Single words
2-3 word phrases
Full sentences

Select all that apply

Teen 2: Does your teen live in the United States?

Yes
No

Teen 2: If your teen does not live in the United States, what country do they live in?

Teen 2: Are you comfortable with us recording your teenager over zoom? (for data analysis we will need to record the interviews and activities. Please note, when we analyze and save data, your name will always be kept separate from your data)

Yes
No

Additional Questions

Is English the language primarily spoken at home?*

Yes
No

If you selected “No” to the previous question, please specify which language is mostly spoken at home*

Do you have access to a computer with reliable access to the internet?*

Yes
No

Please select your timezone*

If you selected “Other” to the previous question, please specify your timezone.*

How did you hear about us?*

SPARK or Simon's Foundation
IAN - Interactive Autism Network
SPED Child & Teen
Resource Fair
Center for Autism Research Excellence (CARE)
Phelan-McDermid Syndrome Foundation (PMSF)
Other

If you selected "Other" to the previous question, please specify how you heard about us*

May we refer you to future studies at our Center?*

Yes
No

GEODE Screener Form

Step 1 of 2

Parent/Guardian Information

Teen 1 Information

Teen 2 Information (Only if applicable)

Additional Questions

Thank you!