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wp6XtzXMKuFUPKMqbusjsixKYkLmjkzux2kqn96Wye29cK4Fouftc

Evaluation of a mental health treatment for depression - Screening Survey

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Do you and the participant live in the same household?

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Yes

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Your city:

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Your state:

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Please provide the following information on the person who would be participating.

First Name:

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Last Name:

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Age in years:

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Phone Number:

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City:

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Preferred pronouns:

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Independent adult? (i.e., does not have a legal guardian or conservator)

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Do you have have someone who knows you well that may be willing to also participate in the study? They will be asked to complete questionnaires and interviews at multiple time points and participate in therapy sessions with you.

Yes

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Would you be willing to also participate in this study? You will be asked to complete questionnaires and interviews at multiple time points and participate in therapy sessions in supporting the participant.

Yes

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Is there another person who would be willing to participate?

Yes

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Have you ever received a diagnosis of Autism Spectrum Disorder (e.g., ASD, Autistic Disorder, Asperger's Syndrome, Pervasive Developmental Disorder, Not Otherwise Specified)?

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Yes

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Has this person ever received a diagnosis of Autism Spectrum Disorder (e.g., ASD, Autistic Disorder, Asperger's Syndrome, Pervasive Developmental Disorder, Not Otherwise Specified)?

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Yes

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At what age were you diagnosed? (in years)

At what age was this person diagnosed? (in years)

Who diagnosed you? Mark all that apply

Psychologist

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Who diagnosed this person? Mark all that apply

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Have you ever been diagnosed with an intellectual disability (ID)?

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Yes

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Has this person ever been diagnosed with an intellectual disability (ID)?

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Yes

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Please specify diagnosis:

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Please specify who gave the diagnosis:

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Do you have other previous mental health diagnoses?

Yes

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Does this person have other previous mental health diagnoses?

Yes

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Please specify the diagnoses:

Is this person currently feeling depressed?

Yes

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Are you currently feeling depressed?

Yes

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How did you hear about this study?

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Please let us know your preferred contact information (if different from above) and some days/times that would be good to reach you:

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