GEODE Screener Page GEODE Screener Form Step 1 of 2 50% 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 InformationToday's Date* MM slash DD slash YYYY Guardian/Parent/Caretaker Name*If you are a participant over 18 years old without a guardian/caretaker, please write 'n/a' in both fields. First Last How may we contact you?*Select all that apply Phone call Text message Email Please select your preferred method of contact* Phone call Text message Email Preferred phone number:*Preferred email address:* Your Relationship to the Participant* Biological Mother Biological Father Non-Biological Mother Non-Biological Father I am the participant (neurotypical) Additional Contact Name First Last Alternative Phone NumberAlternative Email Participant 1 InformationParticipant 1: Name (Participant)* First Last Participant 1: Sex* Male Female Prefer not to answer Participant 1: Date of Birth* Month Day Year Participant 1: Age*(years, month) Participant 1: Has the participant ever been diagnosed with seizures, a seizure disorder (such as epilepsy), or had a history of seizures?* Yes No Participant 1: Does the participant have an official diagnosis of ASD (including PDD-NOS, Autism or Asperger's, or Social Communication Disorder)?* Yes No Participant 1: Does the participant have an official diagnosis of PMS (Phelan-McDermid Syndrome)?* Yes No Participant 1: Has your teen received any interventions?* Yes No Participant 1: Has the participant received at least 6 months of intervention?* Yes No Participant 1: How does the participant most often communicate?*Select all that apply 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 Participant 1: Does the participant live in the United States?* Yes No Participant 1: If the participant does not live in the United States, what country do they live in?* Participant 1: Are you comfortable with us recording the participant 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 Participant 2 Information (Only if applicable)Participant 2: Name First Last Participant 2: Sex Male Female Prefer not to answer Participant 2: Date of Birth Month Day Year Participant 2: Age(years, month) Participant 2: Has the participant ever been diagnosed with seizures, a seizure disorder (such as epilepsy), or had a history of seizures? Yes No Participant 2: Does the participant have an official diagnosis of ASD (including PDD-NOS, Autism or Asperger's, or Social Communication Disorder)? Yes No Participant 2: Has the participant received any interventions? Yes No Participant 2: Has the participant received at least 6 months of intervention? Yes No Participant 2: How does the participant most often communicate?Select all that apply 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 Participant 2: Does the participant live in the United States? Yes No Participant 2: If the participant does not live in the United States, what country do they live in? Participant 2: Are you comfortable with us recording the participant 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 QuestionsIs the caretaker/guardian/parent available to be present during the study?*Please note that this is mandatory for all participants under 18. Yes No 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*Please select your timezoneAlaska (UTC-09:00)American Samoa (UTC-11:00)Atlantic (UTC-04:00)Central (UTC-06:00)Chamorro (UTC+10:00)Eastern (UTC-05:00)Hawaii Aleutian (UTC-10:00)Mountain (UTC-07:00)Pacific (UTC-08:00)OtherIf 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 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.