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value=\"1\">Male</option><option value=\"2\">Intersex</option></select><br/> \n\n    <input type=\"text\" name=\"guardian\" value=\"\" placeholder=\"Guardian Name\" /><br/> \n\n    <input placeholder=\"Date Of Birth (ex 01-DEC-1963)\" type=\"text\" name=\"birth_date\" value=\"\" /><br/> \n\n    <input type=\"text\" name=\"email\" value=\"\" placeholder=\"Email\" /><br/> \n\n    <input type=\"text\" name=\"mobile_phone\" value=\"\" placeholder=\"Mobile Phone\"/><br/> \n\n        <input placeholder=\"Address 1\" type=\"text\" name=\"address1\" value=\"\" /><br/> \n\n        <input placeholder=\"Address Cont.\" type=\"text\" name=\"address2\" value=\"\" /><br/> \n\n        <input placeholder=\"City\" type=\"text\" name=\"city\" value=\"\" /><br/> \n\n        <label>State: </label> \n\n        <select class=\"state\" name=\"state\"> \n\n            <option value=\"\"></option> \n\n            <option value=\"AK\">AK</option><option value=\"AL\">AL</option><option value=\"AR\">AR</option><option value=\"AZ\">AZ</option><option value=\"CA\">CA</option><option value=\"CO\">CO</option><option value=\"CT\">CT</option><option value=\"DC\">DC</option><option value=\"DE\">DE</option><option value=\"FL\">FL</option><option value=\"GA\">GA</option><option value=\"HI\">HI</option><option value=\"IA\">IA</option><option value=\"ID\">ID</option><option value=\"IL\">IL</option><option value=\"IN\">IN</option><option value=\"KS\">KS</option><option value=\"KY\">KY</option><option value=\"LA\">LA</option><option value=\"MA\">MA</option><option value=\"MD\">MD</option><option value=\"ME\">ME</option><option value=\"MI\">MI</option><option value=\"MN\">MN</option><option value=\"MO\">MO</option><option value=\"MS\">MS</option><option value=\"MT\">MT</option><option value=\"NC\">NC</option><option value=\"ND\">ND</option><option value=\"NE\">NE</option><option value=\"NH\">NH</option><option value=\"NJ\">NJ</option><option value=\"NM\">NM</option><option value=\"NV\">NV</option><option value=\"NY\">NY</option><option value=\"OH\">OH</option><option value=\"OK\">OK</option><option value=\"OR\">OR</option><option value=\"PA\">PA</option><option value=\"RI\">RI</option><option value=\"SC\">SC</option><option value=\"SD\">SD</option><option value=\"TN\">TN</option><option value=\"TX\">TX</option><option value=\"UT\">UT</option><option value=\"VA\">VA</option><option value=\"VT\">VT</option><option value=\"WA\">WA</option><option value=\"WI\">WI</option><option value=\"WV\">WV</option><option value=\"WY\">WY</option><option value=\"Argentina\">Argentina</option><option value=\"Australia\">Australia</option><option value=\"Belgium\">Belgium</option><option value=\"Brazil\">Brazil</option><option value=\"Canada\">Canada</option><option value=\"Chile\">Chile</option><option value=\"Costa Rica\">Costa Rica</option><option value=\"Dominican Republic\">Dominican Republic</option><option value=\"East Africa\">East Africa</option><option value=\"France\">France</option><option value=\"Germany\">Germany</option><option value=\"Greece\">Greece</option><option value=\"Honduras\">Honduras</option><option value=\"Hungary\">Hungary</option><option value=\"India\">India</option><option value=\"Ireland\">Ireland</option><option value=\"Italy\">Italy</option><option value=\"Kenya\">Kenya</option><option value=\"Lebanon\">Lebanon</option><option value=\"Mexico\">Mexico</option><option value=\"New Zealand\">New Zealand</option><option value=\"Netherlands\">Netherlands</option><option value=\"Panama\">Panama</option><option value=\"Poland\">Poland</option><option value=\"Portugal\">Portugal</option><option value=\"Puerto Rico\">Puerto Rico</option><option value=\"Romania\">Romania</option><option value=\"Rwanda\">Rwanda</option><option value=\"South Africa\">South Africa</option><option value=\"Spain\">Spain</option><option value=\"Sweden\">Sweden</option><option value=\"Switzerland\">Switzerland</option><option value=\"Turkey\">Turkey</option><option value=\"Ukraine\">Ukraine</option><option value=\"United Kingdom\">United Kingdom</option> \n\n        </select><br/> \n\n        <input placeholder=\"Zip Code\" type=\"text\" name=\"zip_code\" value=\"\" /><br/> \n\n                <label>This study is recruiting patients nationwide. Please select the California site you would prefer to visit (travel expenses are reimbursed).</label> \n\n                <select name=\"custom1\"> \n\n                    <option value=\"\"></option> \n\n                    <option value=\"San Rafael, California (Northern California)\">San Rafael, California (Northern California)</option><option value=\"Glendale, California (Southern California)\">Glendale, California (Southern California)</option><option value=\"Interested in either location\">Interested in either location</option> \n\n                </select><br/> \n\n                <label class=\"select-label\">Does your child have an Autism Spectrum Disorder diagnosis with irritability — like tantrums, aggression, mood swings, crying/screaming outbursts, self-harm, or slamming/banging things?</label> \n\n                <select name=\"custom2\"> \n\n                    <option value=\"\"></option> \n\n                    <option value=\"Yes\">Yes</option><option value=\"No\">No</option><option value=\"Not Sure\">Not Sure</option><option value=\"My child has not been diagnosed with autism\">My child has not been diagnosed with autism</option> \n\n                </select><br/> \n\n                <label class=\"select-label\">Which best describes your child's experience with risperidone (Risperdal) and aripiprazole (Abilify)?</label> \n\n                <select name=\"custom3\"> \n\n                    <option value=\"\"></option> \n\n                    <option value=\"My child has not tried either medication\">My child has not tried either medication</option><option value=\"My child has tried risperidone only\">My child has tried risperidone only</option><option value=\"My child has tried aripiprazole only\">My child has tried aripiprazole only</option><option value=\"My child has tried both, and at least one medication helped\">My child has tried both, and at least one medication helped</option><option value=\"My child tried both, but one or both were stopped early because of side effects or lack of continued access to the medication\">My child tried both, but one or both were stopped early because of side effects or lack of continued access to the medication</option><option value=\"My child tried both, but neither medication helped\">My child tried both, but neither medication helped</option><option value=\"I am not sure\">I am not sure</option> \n\n                </select><br/> \n\n                <input type=\"text\" name=\"custom4\" value=\"\" placeholder=\"Please initial below to be contacted regarding your specified interest. https://www.corticacare.com/privacy-policy\" /><br/> \n\n    <!--**ERRORS START**--><!--**ERRORS END**--> \n\n    <input type=\"button\" onclick=\"reloadSectionWithForm('crio-form', this.form)\" value=\"Submit\" /> \n\n</form> \n\n</div> \n\n            <script type=\"text/javascript\" src=\"https://app.clinicalresearch.io/js/web-form.js\"></script> \n\n            <link rel=\"stylesheet\" href=\"https://app.clinicalresearch.io/css/web-form.css\" /> \n\n            <script type=\"text/javascript\">ajax.get('https://app.clinicalresearch.io/web-form-impression?id=17003');</script> "},"meta":{"canonical":null,"title":"ASD and Irritability Study Interest Form"}}},"pageContext":{"slug":"/research/asd-and-irritability-study-interest-form"}},
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