* ESP CHILDCARE PORTAL
937-528-6460
[email protected]
660 S Main Street
Dayton, Ohio 45402

List others assisting with completion of the questionnaire

As part of submitting data into the Goodwill Easter Seals Miami Valley Online (GESMV) ASQ system, I agree that I am the parent or legal guardian of this child and/or have been granted permission by the parent or legal guardian to submit this screening information. A signed GESMV PERMISSION TO SCREEN form is available for review at the child’s early childhood program. Child screening results and follow-up may be shared with the caregiver completing the screening, the child's listed early childhood program, the legal parent/guardian, and/or the GESMV Child Screening Team.  In the event of a suspected delay or concern, GESMV has permission to make a referral and exchange information with Help Me Grow (applicable to children 0-36 months only), this child’s home school district (children ages 3-5 years), and/or your child’s physician (if physician contact information is listed below by parent).  Intervention services are voluntary programs and parents may accept or refuse participation once a Help Me Grow or school district professional contacts the family.  If concerns are present on your child’s screening, GESMV will attempt to contact the parent or legal guardian by phone or email to discuss these assessment options and gather additional developmental information.  At times, GESMV may run general data reports to share with community stakeholders to determine the effectiveness and scope of the online screening partnership.  This shared data will not include identifiable child information including names or family contact information.

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.