Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ-3™ 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.

Your Participation in the Ages & Stages Questionnaires® (ASQ®) Means:

Ages & Stages Questionnaires® (ASQ®) screenings will be completed on your child’s overall developmental skills. These screens will identify your child’s strengths as well as any areas where your child may need practice or support.

Giving Permission Means:   

·       You freely agree to participate in the ASQ® developmental screenings. 

·       Help Me Grow Kentucky will contact you for future screenings. You can opt out of the future screenings at any time.

·       You agree to Help Me Grow Kentucky sharing information with your health care provider, KEIS, and/or local school district for referrals to services that may help your child.

·       Your child’s ASQ® results will not be released to other people, or programs without your permission.

·       You always have access to all information collected about your child. 

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.