Beacon Interest — Pediatric

Who is completing this form?

Myself Parent/legal guardian Spouse/partner Other caregiver

Full name

Email address

Mobile phone number

US format; used for SMS + call

Preferred contact method

Phone call Text message Email

Best time to reach you

Morning Afternoon Evening Anytime

Child's first name

Child's date of birth

Used to derive the child's age.

Child's sex assigned at birth

Female Male Intersex Prefer not to say

City and state

ZIP / postal code

Primary geo-match signal.

How far would you travel for a study?

Under 10 mi 10–25 mi 25–50 mi 50+ mi Remote/at-home only

Preferred language

English Spanish Other

Preferred language (other)

I agree to be contacted about future research opportunities that may fit me.

I agree to be contacted about future research opportunities.

I have read the privacy notice and understand my information is stored securely and I can opt out anytime.

I have read and accept the privacy notice.

Which apply to your child? Choose any.

Other child condition (please specify)

Diagnosis status

Diagnosed In evaluation No diagnosis (healthy)

Therapies/services your child receives. Choose any.

None ABA Speech Occupational (OT) Physical (PT) Special education/IEP Other

[ASD] Age at diagnosis

In years (or months if <2).

[ASD] Verbal ability

Nonverbal A few words Phrases Fluent

[ASD] Support level (if known)

Level 1 Level 2 Level 3 Not sure

[ASD] Co-occurring conditions. Choose any.

ADHD Anxiety Intellectual disability Epilepsy GI issues None

[Development] Child's current age in months

Critical for infant-study windows.

[Development] Born full-term (37+ weeks)?

Yes No Not sure

[Development] Gestational age at birth (weeks)

[Development] Any complications at birth?

Yes No

[Development] Any developmental concerns?

Yes No

[Development] Normal vision and hearing?

Yes No Not sure

[ADHD] On medication?

Yes No

[ADHD] School accommodations / IEP?

Yes No

[Epilepsy] Seizure frequency

Daily Weekly Monthly A few per year Seizure-free 1yr+

[Epilepsy] On anti-seizure medication?

Yes No