UCLA Study on Gut Bacteria and Brain Health in Teens

Parent's Full Name

Child's Full Name

Parent's / Guardian's Email Address

Parent's / Guardian's Telephone Contact Number

Child's Date of Birth

Format: Month/Day/Year (e.g., 01/15/2000)

Child's Age in years?

City and Zip code

Child's gender assigned at birth?

Male Female Intersex

Was your child adopted?

Adopted from foster care International adoption Formerly maltreated

Which are the best days to contact you?

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Contact for future studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords