Stress & Wellness Study – Screening Questionnaire

Parent/Legal Guardian First and Last Name

Parent/Legal Guardian Email Address

Parent/Legal Guardian Phone Number

Best Day and Time to Contact Parent/Legal Guardian

Please indicate preferred days of the week and time of day

Teen 1's First and Last Name

Teen 1's Month and Year of Birth

Format: Month/Year (e.g., 05/2011)

How old is Teen 1?

Please enter a number only. Teens must be between 12 and 17 years old.

Teen 1's Current Residence (City and State)

Teen 1's Current Zip Code

Teen 1's Phone Number

Best Day and Time to Contact Teen 1

Please indicate preferred days of the week and time of day

Does Teen 1 currently live in California, Tennessee, or Illinois?

Yes No

Is there a second teen interested in participating?

Yes No

Teen 2's First and Last Name

Teen 2's Month and Year of Birth

Format: Month/Year (e.g., 05/2011)

How old is Teen 2?

Please enter a number only. Teens must be between 12 and 17 years old.

Teen 2's Current Residence (City and State)

Teen 2's Current Zip Code

Teen 2's Phone Number

Best Day and Time to Contact Teen 2

Please indicate preferred days of the week and time of day

Does Teen 2 currently live in California, Tennessee, or Illinois?

Yes No

Is there a third teen interested in participating?

Yes No

Teen 3's First and Last Name

Teen 3's Month and Year of Birth

Format: Month/Year (e.g., 05/2011)

How old is Teen 3?

Please enter a number only. Teens must be between 12 and 17 years old.

Teen 3's Current Residence (City and State)

Teen 3's Current Zip Code

Teen 3's Phone Number

Best Day and Time to Contact Teen 3

Please indicate preferred days of the week and time of day

Does Teen 3 currently live in California, Tennessee, or Illinois?

Yes No

Do you (the parent/legal guardian) consent to be contacted about this study?

Yes No

Are you willing to be contacted about future clinical studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords