GEODE Screener Page GEODE Screener Form Step 1 of 2 50% Consent* Yes, I consent No, I do not consent No, I prefer to complete an eligibility interview over the phone 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? Today's Date* MM slash DD slash YYYY Parent's Name* First Last Your Relationship to the Participant (Your Teen)* Biological Mother Biological Father Non-Biological Mother Non-Biological Father Please describe your relationship to the teen E.g., step-mother, adoptive fatherTeen's Name (Participant)* First Last Teen's gender* Male Female Other or prefer not to answer Teen's date of birth* Month Day Year Teen's age* (years, month)How may we contact you?* Phone call Text message Email Select all that applyPlease select your preferred method of contact* Phone call Text message Email Preferred phone number:*Preferred email address:* Additional Contact Name First Last Alternative Phone NumberAlternative Email How did you hear about us?* SPARK or Simon's Foundation IAN - Interactive Autism Network SPED Child & Teen Resource Fair Craigslist Facebook Other Please specify how you heard about us May we refer you to future studies at our Center?* Yes NO Is English the language primarily spoken at home?* Yes No Please specify which language is mostly spoken at home* Has your teen received any interventions?* Yes No Has your teen received at least 6 months of intervention?* Yes No Does your teen have an officialy diagnosis of ASD (including PDD-NOS, Autism or Asperger's, or Social Communication Disorder)? Yes No Third Choice Does your teen live in the United States?* Yes No If your teen does not live in the United States, what country do they live in? How does your child 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 applyDo you have access to a computer or tablet with internet?* Yes No Please select your timezone*Please select your timezoneAlaska (UTC-09:00_American Samoa (UTC-11:00)Atlantic (UTC-04:00)Central (UTC-06:00)Chamorro (UTC+12:00)Eastern (UTC-05:00)Hawaii Aleutian (UTC010:00)Mountain (UTC-07:00)Pacific (UTC-08:00)Other Thank you!Thanks so much for filling out the interest form! You can expect to hear from us shortly. Is there anything else we should know that will help us understand how to work with your teen? Do you have any questions for us? Thank you!Without your consent, we cannot gather information about you. Thank you very much for taking the time to visit CARE's site and for your interest in our study.