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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