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

I have read the provided information about the Ages & Stages questionnaires, and I wish to have my child participate in the online screening program. By proceeding with this form you agree to allow Help Me Grow St. Clair County to review your answers. Our care coordinator will follow up in the next couple of days with your results and activities to support your child's development. With your permission, we may also share your results with your local early childhood support system to ensure your child's needs are met. Your child's non-identifying information will be combined with others in this program, and the data will be studied to help improve access to services for all children in St. Clair County.

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