## Cortica Tourette's Research Interest Form

Gender: Female, Male, Non-Binary  
Sex: Female, Male, Intersex

Which Cortica Research location is most convenient?  
- San Rafael, California (Northern California)  
- Glendale, California (Southern California)  
- I am not local but would be willing to travel (travel expenses are not reimbursed)

Has the participant been diagnosed with Tourette's Syndrome?  
- Yes, I already have a diagnosis from previous physician  
- No, I am seeking a diagnosis

Please select any medications tried for tics or Tourette's Syndrome:

- [ ] Aripiprazole (Abilify)  
- [ ] Risperidone (Risperdal)  
- [ ] Haloperidol (Haldol)  
- [ ] Pimozide (Orap)  
- [ ] Guanfacine (Tenex, Intunive)  
- [ ] Clonidine (Catapres, Kapvay, Onyda XR, Nexiclon XR, Javadin)  
- [ ] Other(s)

Please initial below to be contacted regarding your specified interest. [Cortica Privacy Policy](/content/privacy-policy/index.html)