Cortica Research Interest Form
Gender:
Female
Male
Non-Binary
Sex:
Female
Male
Intersex
What best describes your reason for completing this form?
I am interested in medication-based clinical trials for myself or my child/dependent
I am interested in non-medication clinical trials for myself or my child/dependent
I am a clinician or provider referring a potential participant for a medication-based clinical trial
Please select any diagnoses or conditions that apply to yourself or your child/dependent.
Autism Spectrum Disorder (ASD)
Attention Deficit Hyperactivity Disorder (ADHD)
Tourette's Syndrome / Tic Disorders
Genetic or Rare Syndromes
Developmental or Speech Delay
Anxiety, Depression, or Mood Disorders
Other Neurodevelopmental Condition
Seeking Evaluation/No formal diagnosis
Which of our research locations is most convenient?
Southern California (Glendale, CA)
Northern California (San Rafael, CA)
Other - to discuss with Study Team
