Brookes ASQ | ASQ:SE2 - ASQ-3 English

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Help Me Grow - Escambia

The Arc Gateway, Inc.
Pearl Nelson Center

3932 N Tenth Ave
Pensacola, FL 32503
www.arc-gateway.org

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ-3™ English

Screening Date

I am screening my child today (2024-11-21) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

Screening Date I am screening my child today (2024-11-21) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

I agree to allow Help Me Grow Florida to enter this data into a secure database in order to follow-up with me on the results of this screening and provide me with other relevant sources.

By completing this screening, you are authorizing the information you provide to be released to/from Help Me Grow partners.

Note: By clicking "Submit", you are agreeing to both our Family Access End User License Agreement and any other consent or authorization information outlined on this page.