Hello amazing parents!

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Filling out this form will be of great help to us. You can do this completely anonymously too! The data is for internal use only and will help us potentially help parents of children with autism someday soon. However, if you do want to stay in touch with us as we progress and have more answers, then make sure to fill out your details at the end.

Remember anyone with a child 2-10 years old can fill out the form ASD, ADHD, depression, anxiety or none of the above. Fill out separately for each child you have.

Also check out ANeustart.com if you would like to learn more.

Thanks
Maya Lebow, PhD and Yael Kuperman RD, PhD
Co-Founders of ANeustart
"Putting brain development back on track. Imagine."
For more about us:
Aneustart.com

Sex of child at birth

male

female

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Date of Birth

YYYY

Current weight estimation and unit measurement (for example 16.5kg or 16.5lbs)

Current height and unit measurement (estimation, for example 100 cm or 100 inches )

The child was diagnosed by a professional with *

Autism

ADD/ADHD

Depression

Anxiety

None of the Above

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Other Diagnosis

At what age was the child diagnosed? *

Before the age of 2

Between 2-3 years old

Between 3-4 years old

Between 4-6 years old

Between 6-9 years old

Between 10-12 years old

My child has no official diagnosis

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