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. I will fill out the questionnaire about my child's development and promptly submit the completed questionnaire through this Family Access online questionnaire completion system.

Help Me Grow Kenosha Ages and Stages Online Questionnaire

A unique feature of the Help Me Grow system is that we are able to share a copy of the scored questionnaire with your child’s healthcare provider, school, child care provider, and community resource partners if you wish.  This is a free and optional service that allows you to work cooperatively with those who interact with your child so they can offer higher quality support and services.  Once you receive the results, you will be given the opportunity to provide the name and contact information of any organization or professional with who you would like us to share this information.  No information will be shared without your consent. You can read more information about our  CONSENT FORM  and use of DATA POLICY   

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.