{
    "componentChunkName": "component---src-templates-research-interest-form-template-template-container-jsx",
    "path": "/research/interest-form",
    "result": {"data":{"template":{"slug":"/research/interest-form","title":"Cortica Research Interest Form","htmlContent":{"htmlContent":"<div id=\"crio-form\">\n    <form action=\"https://app.clinicalresearch.io/web-form-save\" method=\"post\">\n    <input type=\"hidden\" name=\"id\" value=\"12510\" /> \n\n<input type=\"text\" name=\"first_name\" value=\"\" placeholder=\"First Name\"/><br/> \n<input type=\"text\" name=\"middle_name\" value=\"\" placeholder=\"Middle Name\"/><br/> \n<input type=\"text\" name=\"last_name\" value=\"\" placeholder=\"Last Name\"/><br/> \n\n<label>Gender: </label><select class=\"gender\" name=\"gender\"><option value=\"\"></option><option value=\"0\">Female</option><option value=\"1\">Male</option><option value=\"2\">Non-Binary</option></select><br/> \n<label>Sex: </label><select class=\"sex\" name=\"sex\"><option value=\"\"></option><option value=\"0\">Female</option><option 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<input type=\"text\" name=\"email\" value=\"\" placeholder=\"Email\" /><br/> \n<input type=\"text\" name=\"mobile_phone\" value=\"\" placeholder=\"Mobile Phone\"/><br/> \n\n            <label>What best describes your reason for completing this form?</label><br/> \n            <ul> \n\n                        <li> \n                            <input type=\"checkbox\" id=\"I am interested in medication-based clinical trials for myself or my child/dependent\" name=\"custom1\" value=\"I am interested in medication-based clinical trials for myself or my child/dependent\" /> \n                            <label for=\"I am interested in medication-based clinical trials for myself or my child/dependent\">I am interested in medication-based clinical trials for myself or my child/dependent</label> \n                        </li> \n\n                        <li> \n                            <input type=\"checkbox\" id=\"I am interested in non-medication clinical trials for myself or my child/dependent\" name=\"custom1\" value=\"I am interested in non-medication clinical trials for myself or my child/dependent\" /> \n                            <label for=\"I am interested in non-medication clinical trials for myself or my child/dependent\">I am interested in non-medication clinical trials for myself or my child/dependent</label> \n                        </li> \n\n                        <li> \n                            <input type=\"checkbox\" id=\"I am a clinician or provider referring a potential participant for a medication-based clinical trial\" name=\"custom1\" value=\"I am a clinician or provider referring a potential participant for a medication-based clinical trial\" /> \n                            <label for=\"I am a clinician or provider referring a potential participant for a medication-based clinical trial\">I am a clinician or provider referring a potential participant for a medication-based clinical trial</label> \n                        </li> \n\n            </ul> \n\n            <label>Please select any diagnoses or conditions that apply to yourself or your child/dependent.</label><br/> \n            <ul> \n\n                        <li> \n                            <input type=\"checkbox\" id=\"Autism Spectrum Disorder (ASD)\" name=\"custom2\" value=\"Autism Spectrum Disorder (ASD)\" /> \n                            <label for=\"Autism Spectrum Disorder (ASD)\">Autism Spectrum Disorder (ASD)</label> \n                        </li> \n\n                        <li> \n                            <input type=\"checkbox\" id=\"Attention Deficit Hyperactivity Disorder (ADHD)\" name=\"custom2\" value=\"Attention Deficit Hyperactivity Disorder (ADHD)\" /> \n                            <label for=\"Attention Deficit Hyperactivity Disorder (ADHD)\">Attention Deficit Hyperactivity Disorder (ADHD)</label> \n                        </li> \n\n                        <li> \n                            <input type=\"checkbox\" id=\"Tourette's Syndrome / Tic Disorders\" name=\"custom2\" value=\"Tourette's Syndrome / Tic Disorders\" /> \n                            <label for=\"Tourette's Syndrome / Tic Disorders\">Tourette's Syndrome / Tic Disorders</label> \n                        </li> \n\n                        <li> \n                            <input type=\"checkbox\" id=\"Genetic or Rare Syndromes\" name=\"custom2\" value=\"Genetic or Rare Syndromes\" /> \n                            <label for=\"Genetic or Rare Syndromes\">Genetic or Rare Syndromes</label> \n                        </li> \n\n                        <li> \n                            <input type=\"checkbox\" id=\"Developmental or Speech Delay\" name=\"custom2\" value=\"Developmental or Speech Delay\" /> \n                            <label for=\"Developmental or Speech Delay\">Developmental or Speech Delay</label> \n                        </li> \n\n                        <li> \n                            <input type=\"checkbox\" id=\"Anxiety, Depression, or Mood Disorders\" name=\"custom2\" value=\"Anxiety, Depression, or Mood Disorders\" /> \n                            <label for=\"Anxiety, Depression, or Mood Disorders\">Anxiety, Depression, or Mood Disorders</label> \n                        </li> \n\n                        <li> \n                            <input type=\"checkbox\" id=\"Other Neurodevelopmental Condition\" name=\"custom2\" value=\"Other Neurodevelopmental Condition\" /> \n                            <label for=\"Other Neurodevelopmental Condition\">Other Neurodevelopmental Condition</label> \n                        </li> \n\n                        <li> \n                            <input type=\"checkbox\" id=\"Seeking Evaluation/No formal diagnosis\" name=\"custom2\" value=\"Seeking Evaluation/No formal diagnosis\" /> \n                            <label for=\"Seeking Evaluation/No formal diagnosis\">Seeking Evaluation/No formal diagnosis</label> \n                        </li> \n\n            </ul> \n\n            <label class=\"select-label\">Which of our research locations is most convenient?</label> \n            <select name=\"custom3\"> \n                <option value=\"\"></option> \n\n                <option value=\"Southern California (Glendale, CA)\">Southern California (Glendale, CA)</option><option value=\"Northern California (San Rafael, CA)\">Northern California (San Rafael, CA)</option><option value=\"Other - to discuss with Study Team\">Other - to discuss with Study Team</option> \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<input type=\"button\" onclick=\"reloadSectionWithForm('crio-form', this.form)\" value=\"Submit\" />\n\n    </form>\n    </div>\n    <script type=\"text/javascript\" src=\"https://app.clinicalresearch.io/js/web-form.js\"></script>\n    <link rel=\"stylesheet\" href=\"https://app.clinicalresearch.io/css/web-form.css\" />\n    <script type=\"text/javascript\">\n    ajax.get('https://app.clinicalresearch.io/web-form-impression?id=12510');\n    </script>\n"},"meta":{"canonical":"https://www.corticacare.com/","title":"Cortica Research Interest Form"}}},"pageContext":{"slug":"/research/interest-form"}},
    "staticQueryHashes": ["1271460761","3953431948"]}