Seeking new directions ... for Autism control

How to Enroll

 

To enroll in the expanded Autism Study, complete the enrollment form below and mail it to TRI

 

TRI

418 N. 38th Street

Omaha, NE  68131

 

or fax it to us at 402-556-5743 or send a scanned image via email to steven.evans@ControlAutismNow.org

 

We will get back in touch with you to make final arrangements to begin the Study with your family member affected by autism.

 

Enrollment Form

Autism Trial Sign-Up Sheet

 

 

Your Name: ___________________________________________________________________

 

Email: _______________________________________________________________________

 

Telephone ____________________ ______________________ ______________________

 

Address: [number/street] ______________________________________________________________

 

Address: [City/State/zip code] _____________________________________________________

 

Autism Client’s Name [and relationship to you]:  _______________________________________

 

Age of Client: _____________ Sex of Client: _________ Age at Diagnosis: _____________

 

Is potential client pregnant?  ______

Has  potential client been diagnosed as psychotic? _____

Has potential client been diagnosed with epilepsy? _____

 

Current Medications [prscriptions and over-the-counter]:

 

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