{"id":170,"date":"2010-08-02T15:02:41","date_gmt":"2010-08-02T19:02:41","guid":{"rendered":"https:\/\/www.bu.edu\/autism\/?page_id=170"},"modified":"2019-08-07T14:50:21","modified_gmt":"2019-08-07T18:50:21","slug":"research-interest-form","status":"publish","type":"page","link":"https:\/\/www.bu.edu\/autism\/contact-us\/research-interest-form\/","title":{"rendered":""},"content":{"rendered":"<h3>Research Interest Form<br style=\"clear: both;\" \/><img loading=\"lazy\" src=\"\/autism\/files\/2019\/07\/longerdots-e1563460517642.png\" alt=\"\" width=\"1539\" height=\"30\" class=\"alignnone wp-image-4767 size-full\" srcset=\"https:\/\/www.bu.edu\/autism\/files\/2019\/07\/longerdots-e1563460517642.png 1539w, https:\/\/www.bu.edu\/autism\/files\/2019\/07\/longerdots-e1563460517642-650x13.png 650w, https:\/\/www.bu.edu\/autism\/files\/2019\/07\/longerdots-e1563460517642-768x15.png 768w, https:\/\/www.bu.edu\/autism\/files\/2019\/07\/longerdots-e1563460517642-1024x20.png 1024w\" sizes=\"(max-width: 1539px) 100vw, 1539px\" \/><\/h3>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Research Interest Form<\/h3>\n                            <p class='gform_description'>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!<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/autism\/wp-json\/wp\/v2\/pages\/170' data-formid='2' >\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_6\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\"><h2 class=\"gsection_title\">Participant Information<\/h2><\/li><li id=\"field_2_7\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Participant Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_2_7'>\n                            \n                            <span id='input_2_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_2_7_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_7_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_2_7_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.4' id='input_2_7_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_7_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_2_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_2_7_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_7_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_37\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_37\"><label class='gfield_label gform-field-label'  >Participant&#039;s Gender<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_37'>\n\t\t\t<li class='gchoice gchoice_2_37_0'>\n\t\t\t\t<input name='input_37' type='radio' value='Male'  id='choice_2_37_0'    \/>\n\t\t\t\t<label for='choice_2_37_0' id='label_2_37_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_37_1'>\n\t\t\t\t<input name='input_37' type='radio' value='Female'  id='choice_2_37_1'    \/>\n\t\t\t\t<label for='choice_2_37_1' id='label_2_37_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_57\"  class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_57\"><label class='gfield_label gform-field-label' for='input_2_57' >Participant Age (years)<\/label><div class='ginput_container ginput_container_number'><input name='input_57' id='input_2_57' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_2_33\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_33\"><label class='gfield_label gform-field-label' for='input_2_33' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_33' id='input_2_33' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_33_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_33_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_33' class='gform_hidden' value='https:\/\/www.bu.edu\/autism\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_45\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_45\"><label class='gfield_label gform-field-label' for='input_2_45' >What are the primary language(s) used in your home?<\/label><div class='gfield_description' id='gfield_description_2_45'>Please specify which language your child is primarily exposed to.<\/div><div class='ginput_container ginput_container_text'><input name='input_45' id='input_2_45' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_45\"    aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_15\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\"><h2 class=\"gsection_title\">DEVELOPMENTAL DIAGNOSIS<\/h2><\/li><li id=\"field_2_16\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_16\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Check all that apply<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_16'><li class='gchoice gchoice_2_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Undiagnosed infant'  id='choice_2_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_1' id='label_2_16_1' class='gform-field-label gform-field-label--type-inline'>Undiagnosed infant<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Autism Spectrum Disorders (Including Asperger&#039;s Syndrome and PDD-NOS)'  id='choice_2_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_2' id='label_2_16_2' class='gform-field-label gform-field-label--type-inline'>Autism Spectrum Disorders (Including Asperger's Syndrome and PDD-NOS)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Language based learning difficulties (Language disorder, Dyslexia, reading deficits, Specific language impairment)'  id='choice_2_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_3' id='label_2_16_3' class='gform-field-label gform-field-label--type-inline'>Language based learning difficulties (Language disorder, Dyslexia, reading deficits, Specific language impairment)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Hearing Impairment'  id='choice_2_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_4' id='label_2_16_4' class='gform-field-label gform-field-label--type-inline'>Hearing Impairment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Neurological conditions (such as Fragile X, Neurofibromatosis, Cerebral Palsy, Tuberous Sclerosis, Brain Injury)'  id='choice_2_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_5' id='label_2_16_5' class='gform-field-label gform-field-label--type-inline'>Neurological conditions (such as Fragile X, Neurofibromatosis, Cerebral Palsy, Tuberous Sclerosis, Brain Injury)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='None'  id='choice_2_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_6' id='label_2_16_6' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Other'  id='choice_2_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_7' id='label_2_16_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.8' type='checkbox'  value='Prefer not to disclose at this time'  id='choice_2_16_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_8' id='label_2_16_8' class='gform-field-label gform-field-label--type-inline'>Prefer not to disclose at this time<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_36\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_36\"><label class='gfield_label gform-field-label' for='input_2_36' >Please Specify Other:<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_2_36' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_34\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_34\"><label class='gfield_label gform-field-label'  >What is your child&#039;s language level?<\/label><div class='gfield_description' id='gfield_description_2_34'>If your child has ASD please specify their level of spoken language<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_34'>\n\t\t\t<li class='gchoice gchoice_2_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Verbally Fluent'  id='choice_2_34_0'    \/>\n\t\t\t\t<label for='choice_2_34_0' id='label_2_34_0' class='gform-field-label gform-field-label--type-inline'>Verbally Fluent<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='Non\/Minimally Verbal'  id='choice_2_34_1'    \/>\n\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1' class='gform-field-label gform-field-label--type-inline'>Non\/Minimally Verbal<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_34_2'>\n\t\t\t\t<input name='input_34' type='radio' value='Infant'  id='choice_2_34_2'    \/>\n\t\t\t\t<label for='choice_2_34_2' id='label_2_34_2' class='gform-field-label gform-field-label--type-inline'>Infant<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_47\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_47\"><label class='gfield_label gform-field-label'  >Does your child have any siblings?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_47'>\n\t\t\t<li class='gchoice gchoice_2_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='Yes'  id='choice_2_47_0'    \/>\n\t\t\t\t<label for='choice_2_47_0' id='label_2_47_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='No'  id='choice_2_47_1'    \/>\n\t\t\t\t<label for='choice_2_47_1' id='label_2_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_62\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_62\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Please select all that apply:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_62'><li class='gchoice gchoice_2_62_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.1' type='checkbox'  value='Older sibling(s)'  id='choice_2_62_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_62_1' id='label_2_62_1' class='gform-field-label gform-field-label--type-inline'>Older sibling(s)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_62_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.2' type='checkbox'  value='Younger sibling(s)'  id='choice_2_62_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_62_2' id='label_2_62_2' class='gform-field-label gform-field-label--type-inline'>Younger sibling(s)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_62_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.3' type='checkbox'  value='Sibling with ASD diagnosis'  id='choice_2_62_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_62_3' id='label_2_62_3' class='gform-field-label gform-field-label--type-inline'>Sibling with ASD diagnosis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_62_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.4' type='checkbox'  value='Sibling less than 9 months old'  id='choice_2_62_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_62_4' id='label_2_62_4' class='gform-field-label gform-field-label--type-inline'>Sibling less than 9 months old<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_13\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\"><h2 class=\"gsection_title\">PRIMARY CONTACT INFORMATION<\/h2><\/li><li id=\"field_2_10\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Preferred Contact Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_10'>\n                            \n                            <span id='input_2_10_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.3' id='input_2_10_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_10_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_10_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.6' id='input_2_10_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_10_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_49\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_49\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Preferred Method of Contact<\/label><div class='gfield_description' id='gfield_description_2_49'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_49'><li class='gchoice gchoice_2_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Email'  id='choice_2_49_1'   aria-describedby=\"gfield_description_2_49\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_49_1' id='label_2_49_1' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='Phone'  id='choice_2_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_49_2' id='label_2_49_2' class='gform-field-label gform-field-label--type-inline'>Phone<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_49_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.3' type='checkbox'  value='Other'  id='choice_2_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_49_3' id='label_2_49_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_52\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_52\"><label class='gfield_label gform-field-label' for='input_2_52' >Please specify other:<\/label><div class='gfield_description' id='gfield_description_2_52'>(e.g., mailing address, etc.)<\/div><div class='ginput_container ginput_container_text'><input name='input_52' id='input_2_52' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_52\"    aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_51\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_51\"><label class='gfield_label gform-field-label' for='input_2_51' >Email Address<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_2_51' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_50\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_50\"><label class='gfield_label gform-field-label' for='input_2_50' >Phone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_2_50' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_54\"  class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_54\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_2_54' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_54_1_container' >\n                                        <input type='text' name='input_54.1' id='input_2_54_1' value=''    aria-required='false'    \/>\n                                        <label for='input_2_54_1' id='input_2_54_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_54_2_container' >\n                                        <input type='text' name='input_54.2' id='input_2_54_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_54_2' id='input_2_54_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_54_3_container' >\n                                    <input type='text' name='input_54.3' id='input_2_54_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_54_3' id='input_2_54_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_54_4_container' >\n                                        <input type='text' name='input_54.4' id='input_2_54_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_54_4' id='input_2_54_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_54_5_container' >\n                                    <input type='text' name='input_54.5' id='input_2_54_5' value=''    aria-required='false'    \/>\n                                    <label for='input_2_54_5' id='input_2_54_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_2_54_6_container' >\n                                        <select name='input_54.6' id='input_2_54_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_2_54_6' id='input_2_54_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_43\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_43\"><label class='gfield_label gform-field-label'  >What is your country of residence<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_43'>\n\t\t\t<li class='gchoice gchoice_2_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='United States'  id='choice_2_43_0'    \/>\n\t\t\t\t<label for='choice_2_43_0' id='label_2_43_0' class='gform-field-label gform-field-label--type-inline'>United States<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='gf_other_choice'  id='choice_2_43_1'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_2_43_other' name='input_43_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_41\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_41\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >How did you hear about us?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_41'><li class='gchoice gchoice_2_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='SPARK or Simon&#039;s Foundation'  id='choice_2_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_1' id='label_2_41_1' class='gform-field-label gform-field-label--type-inline'>SPARK or Simon's Foundation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='IAN- Interactive Autism Network'  id='choice_2_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_2' id='label_2_41_2' class='gform-field-label gform-field-label--type-inline'>IAN- Interactive Autism Network<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_41_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.3' type='checkbox'  value='SPED Child &amp; Teen'  id='choice_2_41_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_3' id='label_2_41_3' class='gform-field-label gform-field-label--type-inline'>SPED Child & Teen<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_41_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.4' type='checkbox'  value='Resource Fair'  id='choice_2_41_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_4' id='label_2_41_4' class='gform-field-label gform-field-label--type-inline'>Resource Fair<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_41_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.5' type='checkbox'  value='Craigslist'  id='choice_2_41_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_5' id='label_2_41_5' class='gform-field-label gform-field-label--type-inline'>Craigslist<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_41_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.6' type='checkbox'  value='Facebook'  id='choice_2_41_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_6' id='label_2_41_6' class='gform-field-label gform-field-label--type-inline'>Facebook<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_41_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.7' type='checkbox'  value='Boston Metro'  id='choice_2_41_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_7' id='label_2_41_7' class='gform-field-label gform-field-label--type-inline'>Boston Metro<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_41_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.8' type='checkbox'  value='Printed recruitment materials (brochures, flyers, etc)'  id='choice_2_41_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_41_8' id='label_2_41_8' class='gform-field-label gform-field-label--type-inline'>Printed recruitment materials (brochures, flyers, etc)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_41_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.9' type='checkbox'  value='Autism Awareness Event'  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aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_55\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_55\"><label class='gfield_label gform-field-label' for='input_2_55' >Who referred you?<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_2_55' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_46\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_46\"><label class='gfield_label gform-field-label'  >Are you interested in being referred to affiliated\/future studies?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_46'>\n\t\t\t<li class='gchoice gchoice_2_46_0'>\n\t\t\t\t<input name='input_46' type='radio' 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