2026 Ketogenic Therapy in Action! for Youth and Families
The purpose of this questionnaire is submit preliminary interest to participate in the CMHRC ketogenic therapy research study and/or program. You will receive an follow-up email from keto@cmhrc.org with information about next steps.
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.
First and last name of intended participant (if different from above):
First Name
Last Name
Participant's date of birth:
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Relationship between person filling out this form and participant (check all that apply):
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Self
Partner
Parent
Legal guardian
Caregiver
Other
Participants current age is:
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5 years old or younger
6-9 years old
10-13 years old
14-17 years old
18-20 years old
21 years old or older
We are interested in learning more about participating in:
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Keto Research Study
Keto Fee-for-Service Program
Both
Unsure
Participant has been given an official diagnosis of (select all that apply):
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Attention Deficit Hyperactivity Disorder (ADHD)
Autism Spectrum Disorder (ASD)
Bipolar Disorder (types include: Type I, Type II, and Unspecified)
Cyclothymic Disorder
Disruptive Mood Dysregulation Disorder (DMDD)
Generalized Anxiety Disorder
Major Depressive Disorder
Persistent Depressive Disorder
Obsessive Compulsive Disorder
Oppositional Defiant Disorder
Panic Disorder
Post Traumatic Stress Disorder (PTSD or Complex PTSD)
Reactive Attachment Disorder (RAD)
Separation Anxiety Disorder
Social Anxiety Disorder
Thermoregulatory Sleep Dysregulation Disorder (aka FOH)
Unspecified Anxiety Disorder
Unspecified Mood Disorder
None of the above (specify below if possible)
Participant has been given the following diagnosis that wasn't listed above:
Even though the participant has not been given an official diagnosis I/we suspect that they may have the following diagnosis (select all that apply):
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Attention Deficit Hyperactivity Disorder (ADHD)
Autism Spectrum Disorder (ASD)
Bipolar Disorder (types include: Type I, Type II, and Unspecified)
Cyclothymic Disorder
Disruptive Mood Dysregulation Disorder (DMDD)
Generalized Anxiety Disorder
Major Depressive Disorder
Mood Disorder Unspecified
Persistent Depressive Disorder
Obsessive Compulsive Disorder
Oppositional Defiant Disorder
Panic Disorder
Post Traumatic Stress Disorder (PTSD or Complex PTSD)
Reactive Attachment Disorder (RAD)
Separation Anxiety Disorder
Social Anxiety Disorder
Thermoregulatory Sleep Dysregulation Disorder (aka FOH)
Unspecified Anxiety Disorder
Unspecified Mood Disorder
None of the above (specify below if possible)
Even though the participant has not been given an official diagnosis I/we suspect that they may have the following diagnosis that wasn't listed above:
Participant has access to a psychiatric professional for ongoing care?
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Yes
No
Unsure
If yes, participant is able to regularly see the following providers (select all that apply):
Psychiatrist
Psychiatric Nurse Practitioner
Another professional who prescribes psychiatric medication
Psychotherapist (includes social workers, family therapists, psychologists, etc.)
If no, please describe obstacles to accessing care.
Participant (and/or family) eats a vegetarian or vegan diet.
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Yes
No
Unsure
If yes, is the participant is willing to eat animal protein for the duration of participation.
Yes
No
Unsure
Participant is willing and able to make dietary changes.
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Yes
No
Unsure
Participant has been diagnosed with Type 1 Diabetes.
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Yes
No
Unsure
Participant identifies as the following gender:
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Female
Male
Nonbinary
Transgender
Genderfluid
Other
Participant 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
What state does the participant live in?
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Participant was adopted.
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Yes
No
Unsure
Participant was previously in the foster care system.
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Yes
No
Unsure
Participant 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:
Please select one of the following options:
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I am aged 18 or older and I would like to submit myself to be considered for participation.
I am the legal guardian and/or have legal custody of a minor child who we would like to be considered for participation.
I am the legal guardian, have legal custody, or have medical power of attorney for an adult who we would like to be considered for participation.
I am a parent and/or caregiver for a young adult (ages 18-20) and would like them to be considered for participation.
None of the above (specify below if possible)
If answered "none of the above" in the previous answer, please explain your legal right for submitting someone else for consideration.
I give my consent to be contacted by CMHRC via email or phone.
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Yes
No
I understand that all survey responses are kept confidential and stored in CMHRC's private ketogenic therapy study database. Prospective subject families that do not qualify for the research study will be offered a spot in a separate non-researched based program. The information collected in this survey will not be shared outside of CMHRC and research staff.
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Yes
No
I give my permission for my answers to this survey to be stored by CMHRC in order to communicate directly with me when new opportunities to participate in research or other programs arise.
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Yes
No
Submit
Should be Empty: