First Name *

Last Name *

Phone *

Email *

City

State *

Postal code *

Please select the brands of baby food you purchased and fed your child. *

Happy Family Organics and HappyBABY

Beech-Nut

Earth’s Best Organic

Plum Organics

Parent’s Choice

Sprout Organic Food

Gerber

Other

Did your child receive a medical diagnosis of Autism? *

Yes

No

Did your child receive a medical diagnosis of Asperger’s Disorder? *

Yes

No

Did your child receive a medical diagnosis of ADHD? *

Yes

No

Your Chil's current age *

Your Child's age at the time of diagnosis

Aditional information you want to share