2024 Ketogenic Therapy in Action!
Preliminary interest in participation in the Keto for kids program. It is important to us and our funder that we ensure that those of all backgrounds have an equal opportunity to participate in this program. Thank you for filling out this survey.
Name of Person Filling Out This Form
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First Name
Last Name
Email of Person Filling Out This Form
*
example@example.com
Phone Number of Person Filling Out This Form
*
Please enter a valid phone number.
Format: (000) 000-0000.
My child's current age is:
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6-9 years old
10-13 years old
14-17 years old
My child is 5 years old or younger
My child is 18 years old or older
My child will turn 18 on or before June 1st, 2025
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Yes
No
My child has been given a diagnosis of (select all that apply):
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Bipolar Disorder (types include: Type I, Type II, and Unspecified)
Disruptive Mood Dysregulation Disorder (DMDD)
Attention Deficit Hyperactivity Disorder (ADHD)
Major Depressive Disorder
Mood Disorder Unspecified
None of the above
My child has been given the following diagnosis that wasn't listed above:
Even though we haven't been given a diagnosis, I suspect my child may have the following disorder:
Bipolar Disorder (types include: Type I, Type II, and Unspecified)
Disruptive Mood Dysregulation Disorder (DMDD)
Attention Deficit Hyperactivity Disorder (ADHD)
Major Depressive Disorder
Mood Disorder Unspecified
None of the above
Even though we haven't been given a diagnosis, I suspect my child has the following diagnosis that wasn't listed above:
My child (and/or our family) eats a vegetarian or vegan diet.
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Yes
No
Unsure
If yes, are you willing to have your child eat animal protein for the duration of study/program participation.
Yes
No
Unsure
My child is willing and able to make dietary changes to support mental health stability.
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Yes
No
Unsure
My child has been diagnosed with Type 1 Diabetes.
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Yes
No
Unsure
My child identifies as the following gender:
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Female
Male
Nonbinary
Transgender
Genderfluid
Other
My child identifies as the following race:
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White / Caucasian
Latinx/Hispanic
Black or African American
Asian / Pacific Islander
American Indian or Alaskan Native
Other
My child was adopted.
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Yes
No
Unsure
My child was previously in the foster care system.
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Yes
No
Unsure
My child is currently in the foster care system.
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Yes
No
Unsure
If you have answered "unsure" to any of the above questions, please provide a brief explanation below:
I am legal guardian and/or have legal custody of my children.
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Yes
No
I want more information about participating in this program.
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Yes
No
I give my consent to be contacted by CMHRC via email or phone.
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Yes
No
Submit
Should be Empty: