Trayt: Pilot Study Enrollment Survey

Thank you for your interest in the Trayt Pilot Program.

Please complete the form below and a Trayt program coordinator will follow-up with you.

Please note that the pilot study is only available to iPhone users at this time. Android and web users, stay tuned for updates on the Trayt Android app and web portal releases.

First Name *

Last Name *

Email Address *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

How old is your child? *

3 - 6

7 - 10

11 - 15

16 +

Has your child been diagnosed with any of the following? *

Is your child currently taking any medications? *

Yes

No

How many care providers does your child have? (Physicians, therapists, etc.) *

0 - 3

4 - 6

7+

Which therapy/therapies does your child participate in? *

Why are you interested in enrolling? *

Do you use, or do you have access to an iPhone? *

Yes

No