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



418 N. 38th Street

Omaha, NE  68131


or fax it to us at 402-556-5743 or send a scanned image via email to


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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