Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

Please note our permissions have been updated to allow Metro United Way to make referrals on your behalf

METRO UNITED WAY’S DEVELOPMENTAL SCREENING HUB

PARENT/LEGAL GUARDIAN CONSENT TO SCREEN, OBTAIN, AND RELEASE INFORMATION

YOUR PARTICIPATION IN THE DEVELOPMENTAL SCREENING HUB MEANS:

You will complete Ages & Stages Questionnaires® (ASQ®) screenings to measure your child’s development. These screenings will identify your child’s strengths and any areas where your child may need practice or support. Whether or not you choose to complete the ASQ® for your child, Metro United Way can connect you to resources as needed.

GIVING PERMISSION MEANS:

1. Your child’s ASQ® results will not be shared without your permission. Your child’s information will be shared only with you, your healthcare provider, Play Cousins Collective, and the provider(s) you choose.
2. You always have access to all information collected by Metro United Way’s Developmental Screening Hub (The Screening Hub) about your child.
3. You agree to ongoing communication and/or screenings through The Screening Hub. You can stop participating at any time. This communication (via phone, email, or paper copy) may occasionally contain protected health information.
4. You agree that The Screening Hub has your permission to use the personal health information of your child, a minor. You also agree that you are the parent or legal guardian of the child whose name is entered and may consent to the use of such information by the Screening Hub.
5. The Screening Hub doesn’t provide medical advice for your child’s condition. The Screening Hub can connect you to community resources for their development, behavior, or learning. A team member will conduct follow-up care coordination if you choose.
6. Every effort will be made to keep the information you share confidential. By enrolling, you agree that The Screening Hub may use any information you share as they consider appropriate to meet the purposes of The Screening Hub.
7. The Screening Hub will make referrals to JCPS Preschool, JCPS Exceptional Child Education (ECE), Healthy Start, Kynect (Child Care Assistance Program), Ohio Valley Educational Cooperative, Greater Louisville Head Start, Heuser Hearing Institute, Kentucky's Early Intervention System (KEIS, formerly First Steps), Kids Center, or Associates in Pediatric Therapy as it deems appropriate. However, The Screening Hub does not make any guarantees for services you or your child receive.

HOW ASQ INFORMATION IS SHARED:

To better communicate and facilitate your participation in the program, Metro United Way will be providing Play Cousins Collective with limited access to your family/child’s information.

Play Cousins will have access to:

• General contact information
• Interactions between the developmental screening coordinators and your family
• Your participation rates and if you are due for a gift card
• Any needed services and any information regarding referrals made by Metro United Way and/or connections made by your family

By submitting this form, you attest to being the LEGAL guardian of the child listed above, agree to enroll your child into the Ages and Stages Developmental Screening Hub, and share your ASQ results with the agencies listed above. This consent is valid until your child reaches age six or until notified by parent/guardian.

The authorization must be signed and dated and may be revoked by notifying Metro United Way Office, 334 East Broadway, Louisville KY 40202, in writing at any time except to the extent action has been taken prior to revocation. This consent will expire upon the patient’s sixth birthdate. PURPOSE: Continuity of Care

Kentucky Law directs health care providers to furnish to a patient, at the patient’s request, one free copy of the patient’s Medical Record. I understand that the medical record released pursuant to this authorization could contain information concerning drug related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood borne infectious disease, which are subject to federal and/or state restrictions on disclosure. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medical record for the purpose and extent stated above

PROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by federal and/ or state law. Federal and state regulations prohibit you (the recipient) from making any further disclosures without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

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.