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Referral Screening – 1.1

Thank you for registering your interest in our research. We will ask you a few questions to assess whether your child is suitable for our study using micronutrients to help balance emotions and irritability in teens. We will not use your information for any other purpose than assessing eligibility for research conducted in the Mental Health and Nutrition Research Lab. These questions should only take a couple of minutes to complete and we will be in touch with you to let you know if your child is eligible after you submit the questions.

I understand that the information that I provide will be used for the purposes of assessing my child’s eligibility to take part in this study and all personal information gained about me will be kept strictly confidential at all times.

Are you and your child willing to meet with us on-line, answer questionnaires, and participate in the study for the full length of time (4 months)?

Do you think your child could take up to 12 pills a day (four, three times a day with meals) for 4 months?

Your full name

Your address (street number, street name, city, postcode)

Your phone number (home/mobile)

Please also include the name of your mobile provider, in case we need to supply a top-up.

Your email address

Your child's date of birth

Your child's gender:

Your child's full name

Your child's phone number (home/mobile)

Please also include the name of their mobile provider, in case we need to supply a top-up.

Your child's email address.

Your child will need their OWN email address so that we can track responses from individuals.

Is your child between the ages of 12 and 17?

Please indicate which of the following ethnic groups your child belongs to (you may select more than one)

If 'other' please state in the comment box provided.

Is your child at school (primary or secondary)?

If yes, please tell us which school AND what year your child is in.

Is your child taking any medications currently?

If yes, please list the name of EACH medication AND the reason your child is taking each medication.

Has your child taken any medication for psychological concerns in the past four weeks?

If yes, please name the medication taken for psychological concerns.

Has your child been diagnosed with any psychiatric/psychological problems (e.g. ADHD, anxiety, depression, autism, intellectual disability)?

If yes, please tell us which psychiatric/psychological problem(s) were diagnosed AND by whom (if you know).

Does your child suffer from any physical health issues?

If yes, please describe the health issues your child experiences in the comment box below:

Does your child have any difficulties metabolising minerals (e.g. Wilson's disease, haemochromatosis)?

If yes, please tell us what metabolising difficulties your child has.

Does your child have any specific allergies?

If yes, please describe your child's allergies in the comment box below:

Does your child currently suffer from any serious medical conditions that might require hospitalisation?

If yes, please describe the condition that may require hospitalisation in the comment box below:

Does your child currently take any herbal/nutritional supplements or formulations (e.g. vitamins, minerals, omega3s, probiotics, melatonin, St John's Wort)?

If yes, please list what products your child takes AND the dose (if known) in the comment box below (e.g. Omega 3: 500mg a day):

Where did you hear about this study (tick all that apply)?

If you selected poster, brochure and/or word of mouth, please let us know where you saw/heard about the study in the comment box below (e.g. at the doctors office).

Please indicate your preferred days for us to call.

Please indicate the times at which you would be available for us to call you. You can select more than one option.

Note:  If you can make an appointment between 9am and 2pm you may be seen sooner.

Please feel free to tell us anything else we might need to know:

Please let us know what your preferred method of communication is:

We will send weekly reminders via email or text with links to the questionnaires that need filling in that day. Are you and your teen able to fill in weekly questionnaires online as part of this research?

Most weekly questionnaires should take around 10 minutes to complete.

Please outline one or two behaviours or symptoms that you believe to be your teen's biggest problem.

What is your teen most concerned about?