{"id":7637,"date":"2025-03-17T11:40:11","date_gmt":"2025-03-17T15:40:11","guid":{"rendered":"https:\/\/www.bu.edu\/autism\/?page_id=7637"},"modified":"2025-03-17T11:40:14","modified_gmt":"2025-03-17T15:40:14","slug":"project-echo-screener-form","status":"publish","type":"page","link":"https:\/\/www.bu.edu\/autism\/project-echo-screener-form\/","title":{"rendered":"Project ECHO Screener Form"},"content":{"rendered":"<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 gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_37' style='display:none'><div id='gf_37' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Project ECHO Eligibility Form<\/h2>\n                            <p class='gform_description'>This form is used to determine initial eligibility for Project ECHO.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_37'  action='\/autism\/wp-json\/wp\/v2\/pages\/7637#gf_37' data-formid='37' >\n        <div id='gf_progressbar_wrapper_37' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>2<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_37_1' class='gform_page ' data-js='page-field-id-46' >\n                                    <div class='gform_page_fields'><div id='gform_fields_37' class='gform_fields top_label form_sublabel_below description_above'><fieldset id=\"field_37_1\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_1\"><legend class='gfield_label gform-field-label'  >Consent<\/legend><div class='gfield_description' id='gfield_description_37_1'>We need your consent to gather information about you and your child. This information will be used to determine whether you are eligible to participate in this study. \n\nYou don't have to answer any questions you don't want to and you can stop filling out this form at any point. All information provided by you will be kept confidential. Only our project staff will have access to the information for research purposes.\nDo you consent to answering these questions so we can know more about you and your child?\n\nIf you prefer to complete our eligibility screener over the phone, you can contact the project ECHO research team at echocare@bu.edu or 617-358-4474. <\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_1'>\n\t\t\t<div class='gchoice gchoice_37_1_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='Yes, I consent.'  id='choice_37_1_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_37_1\"   \/>\n\t\t\t\t\t<label for='choice_37_1_0' id='label_37_1_0' class='gform-field-label gform-field-label--type-inline'>Yes, I consent.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_1_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='No, I do not consent.'  id='choice_37_1_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_1_1' id='label_37_1_1' class='gform-field-label gform-field-label--type-inline'>No, I do not consent.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_37_3' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_37\").val(\"2\");  jQuery(\"#gform_37\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_37\").val(\"2\");  jQuery(\"#gform_37\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_37_2' class='gform_page' data-js='page-field-id-3' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_37_2' class='gform_fields top_label form_sublabel_below description_above'><fieldset id=\"field_37_6\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_6\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Today&#039;s Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_37_6' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_37_6_1_container'>\n                                            <input type='text' maxlength='2' name='input_6[]' id='input_37_6_1' value=''   aria-required='true'   placeholder='MM' \/>\n                                            <label for='input_37_6_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_37_6_2_container'>\n                                            <input type='text' maxlength='2' name='input_6[]' id='input_37_6_2' value=''   aria-required='true'   placeholder='DD' \/>\n                                            <label for='input_37_6_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_37_6_3_container'>\n                                            <input type='text' maxlength='4' name='input_6[]' id='input_37_6_3' value=''   aria-required='true'   placeholder='YYYY'   \/>\n                                            <label for='input_37_6_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_37_7\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_7\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><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_37_7'>\n                            \n                            <span id='input_37_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_37_7_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_37_7_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_37_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_37_7_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_37_7_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_37_9\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_9\"><legend class='gfield_label gform-field-label'  >Your relationship to the child?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_9'>\n\t\t\t<div class='gchoice gchoice_37_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Biological mother'  id='choice_37_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_9_0' id='label_37_9_0' class='gform-field-label gform-field-label--type-inline'>Biological mother<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Biological father'  id='choice_37_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_9_1' id='label_37_9_1' class='gform-field-label gform-field-label--type-inline'>Biological father<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Non-biological mother'  id='choice_37_9_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_9_2' id='label_37_9_2' class='gform-field-label gform-field-label--type-inline'>Non-biological mother<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_9_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Non-biological father'  id='choice_37_9_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_9_3' id='label_37_9_3' class='gform-field-label gform-field-label--type-inline'>Non-biological father<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_9_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='gf_other_choice'  id='choice_37_9_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_9_4' id='label_37_9_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_37_9_other' class='gchoice_other_control' name='input_9_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_37_10\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_10\"><label class='gfield_label gform-field-label' for='input_37_10' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_37_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_37_11\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_11\"><label class='gfield_label gform-field-label' for='input_37_11' >Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_37_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_37_12\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_12\"><legend class='gfield_label gform-field-label'  >Please select your preferred method of contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_12'>\n\t\t\t<div class='gchoice gchoice_37_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Phone call'  id='choice_37_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_12_0' id='label_37_12_0' class='gform-field-label gform-field-label--type-inline'>Phone call<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Text message'  id='choice_37_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_12_1' id='label_37_12_1' class='gform-field-label gform-field-label--type-inline'>Text message<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_12_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Email'  id='choice_37_12_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_12_2' id='label_37_12_2' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_13\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_13\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Child&#039;s Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><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_37_13'>\n                            \n                            <span id='input_37_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_37_13_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_37_13_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_37_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_37_13_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_37_13_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_37_14\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_14\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Child&#039;s Date of Birthday<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_37_14' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_37_14_1_container'>\n                                            <input type='text' maxlength='2' name='input_14[]' id='input_37_14_1' value=''   aria-required='true'   placeholder='MM' \/>\n                                            <label for='input_37_14_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_37_14_2_container'>\n                                            <input type='text' maxlength='2' name='input_14[]' id='input_37_14_2' value=''   aria-required='true'   placeholder='DD' \/>\n                                            <label for='input_37_14_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_37_14_3_container'>\n                                            <input type='text' maxlength='4' name='input_14[]' id='input_37_14_3' value=''   aria-required='true'   placeholder='YYYY'   \/>\n                                            <label for='input_37_14_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_37_41\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_41\"><label class='gfield_label gform-field-label' for='input_37_41' >Child&#039;s age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_37_41'>years, months<\/div><div class='ginput_container ginput_container_text'><input name='input_41' id='input_37_41' type='text' value='' class='large'  aria-describedby=\"gfield_description_37_41\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_37_18\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_18\"><legend class='gfield_label gform-field-label'  >Child&#039;s Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_18'>\n\t\t\t<div class='gchoice gchoice_37_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Female'  id='choice_37_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_18_0' id='label_37_18_0' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Male'  id='choice_37_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_18_1' id='label_37_18_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_18_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Other or prefer not to respond'  id='choice_37_18_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_18_2' id='label_37_18_2' class='gform-field-label gform-field-label--type-inline'>Other or prefer not to respond<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_19\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_19\"><legend class='gfield_label gform-field-label'  >Is English the primary language spoken to your child at home?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_19'>\n\t\t\t<div class='gchoice gchoice_37_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_37_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_19_0' id='label_37_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_37_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_19_1' id='label_37_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_37_21\"  class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_21\"><label class='gfield_label gform-field-label' for='input_37_21' >What percentage of time does your child hear English?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_21' id='input_37_21' type='text'    value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_37_22\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_22\"><legend class='gfield_label gform-field-label'  >Was your child carried full-term to 32 weeks or more?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_22'>\n\t\t\t<div class='gchoice gchoice_37_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_37_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_22_0' id='label_37_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_37_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_22_1' id='label_37_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_37_23\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_23\"><label class='gfield_label gform-field-label' for='input_37_23' >At how many weeks was your child born?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_37_23' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_37_24\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_24\"><legend class='gfield_label gform-field-label'  >Does your child have any developmental disorders or disabilities, such as autism or ADHD<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_24'>\n\t\t\t<div class='gchoice gchoice_37_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_37_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_24_0' id='label_37_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_37_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_24_1' id='label_37_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_37_25\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_25\"><label class='gfield_label gform-field-label' for='input_37_25' >Has your child received an official diagnosis of Autism Spectrum Disorder, Asperger&#039;s Syndrome, or PDD-NOS?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_37_25' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_37_26\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_26\"><legend class='gfield_label gform-field-label'  >Do you have any concerns about your child&#039;s development, or has a health professional ever expressed concerns about your child&#039;s speech or language development?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_26'>\n\t\t\t<div class='gchoice gchoice_37_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_37_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_26_0' id='label_37_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_37_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_26_1' id='label_37_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_27\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_27\"><legend class='gfield_label gform-field-label'  >How many spoken words does your child have?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_37_27'>Echoed words count!<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_27'>\n\t\t\t<div class='gchoice gchoice_37_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Zero'  id='choice_37_27_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_37_27\"   \/>\n\t\t\t\t\t<label for='choice_37_27_0' id='label_37_27_0' class='gform-field-label gform-field-label--type-inline'>Zero<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='1-20'  id='choice_37_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_27_1' id='label_37_27_1' class='gform-field-label gform-field-label--type-inline'>1-20<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='21-49'  id='choice_37_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_27_2' id='label_37_27_2' class='gform-field-label gform-field-label--type-inline'>21-49<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_27_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='50+'  id='choice_37_27_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_27_3' id='label_37_27_3' class='gform-field-label gform-field-label--type-inline'>50+<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_30\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_30\"><legend class='gfield_label gform-field-label'  >Does your child have any genetic syndromes?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_30'>\n\t\t\t<div class='gchoice gchoice_37_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_37_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_30_0' id='label_37_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_37_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_30_1' id='label_37_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_29\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_29\"><legend class='gfield_label gform-field-label'  >Does your child have a seizure disorder?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_29'>\n\t\t\t<div class='gchoice gchoice_37_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_37_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_29_0' id='label_37_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_37_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_29_1' id='label_37_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_28\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_28\"><legend class='gfield_label gform-field-label'  >Has your child ever had a severe head injury or traumatic brain injury?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_28'>\n\t\t\t<div class='gchoice gchoice_37_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Yes'  id='choice_37_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_28_0' id='label_37_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_37_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_28_1' id='label_37_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_31\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_31\"><legend class='gfield_label gform-field-label'  >Does your child have any siblings or first-degree relatives with a diagnosis of autism spectrum disorder?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_31'>\n\t\t\t<div class='gchoice gchoice_37_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_37_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_31_0' id='label_37_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_37_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_31_1' id='label_37_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_42\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_42\"><legend class='gfield_label gform-field-label'  >Is your child currently taking any medication (for any condition)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_42'>\n\t\t\t<div class='gchoice gchoice_37_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_37_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_42_0' id='label_37_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_37_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_42_1' id='label_37_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_45\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_45\"><legend class='gfield_label gform-field-label'  >If yes, how long has your child been taking this medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_45'>\n\t\t\t<div class='gchoice gchoice_37_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Less than two weeks'  id='choice_37_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_45_0' id='label_37_45_0' class='gform-field-label gform-field-label--type-inline'>Less than two weeks<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Two weeks or more'  id='choice_37_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_45_1' id='label_37_45_1' class='gform-field-label gform-field-label--type-inline'>Two weeks or more<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_43\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_43\"><legend class='gfield_label gform-field-label'  >Has your child stopped taking any medication in the past month?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_43'>\n\t\t\t<div class='gchoice gchoice_37_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_37_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_43_0' id='label_37_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_37_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_43_1' id='label_37_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_44\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_44\"><legend class='gfield_label gform-field-label'  >If yes, when did your child stop taking the medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_44'>\n\t\t\t<div class='gchoice gchoice_37_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Less than two weeks ago'  id='choice_37_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_44_0' id='label_37_44_0' class='gform-field-label gform-field-label--type-inline'>Less than two weeks ago<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Two weeks ago, or more'  id='choice_37_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_44_1' id='label_37_44_1' class='gform-field-label gform-field-label--type-inline'>Two weeks ago, or more<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_32\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_32\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Does your child have:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_37_32'><div class='gchoice gchoice_37_32_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.1' type='checkbox'  value='Food allergies or dietary restrictions?'  id='choice_37_32_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_32_1' id='label_37_32_1' class='gform-field-label gform-field-label--type-inline'>Food allergies or dietary restrictions?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_32_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.2' type='checkbox'  value='Sensory sensitivities?'  id='choice_37_32_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_32_2' id='label_37_32_2' class='gform-field-label gform-field-label--type-inline'>Sensory sensitivities?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_32_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.3' type='checkbox'  value='Any aversions to wearing a hat?'  id='choice_37_32_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_32_3' id='label_37_32_3' class='gform-field-label gform-field-label--type-inline'>Any aversions to wearing a hat?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_32_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.4' type='checkbox'  value='Self-injurious or aggressive behaviors?'  id='choice_37_32_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_32_4' id='label_37_32_4' class='gform-field-label gform-field-label--type-inline'>Self-injurious or aggressive behaviors?<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_37_35\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_35\"><label class='gfield_label gform-field-label' for='input_37_35' >What foods are restricted?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_37_35' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_37_36\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_36\"><label class='gfield_label gform-field-label' for='input_37_36' >Please describe any sensory sensitivities<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_37_36' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_37_37\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_37\"><label class='gfield_label gform-field-label' for='input_37_37' >Please describe self-injurious or aggressive behaviors<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_37_37' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_37_38\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_38\"><label class='gfield_label gform-field-label' for='input_37_38' >What does your child like as rewards?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_37_38'>For example: positive praise, snacks, specific toys<\/div><div class='ginput_container ginput_container_text'><input name='input_38' id='input_37_38' type='text' value='' class='large'  aria-describedby=\"gfield_description_37_38\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_37_39\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_37_39\"><label class='gfield_label gform-field-label' for='input_37_39' >Is there anything else we should know that will help us understand how to best work with your child?<\/label><div 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