Brookes ASQ | ASQ:SE2 - ASQ-3 English

Walled Lake Schools Preschool Office

615 N. Pontiac Trail, Walled Lake, MI 48390

248.956.5080

[email protected]

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 (2024-12-22) 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 (2024-12-22) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

Participation in this project is voluntary and at no cost to you. Your child’s results are confidential and will not be shared outside of the Great Start Developmental Screening Project. Your results will be sent to you as well as Walled Lake Schools. Your child’s non-identifying information will also be combined with that of others in this program and the data will be studied to help improve access to services for all children in the county.

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