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

By providing my child's health care provider information, I agree to allow Metro United Way (MUW) to share information about my child and my child's ASQ results with my health care provider. You may opt out at any time by contacting kimberly.broecker@metrounitedway.org

To better communicate and facilitate your participation in the program, If you are involved or enrolled with Play Cousins Collective, or their advocates, Metro United Way will be providing Play Cousins Collective with limited access to of 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 the family.

You may opt out at any time by contacting kimberly.broecker@metrounitedway.org.

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.