Brookes ASQ | ASQ:SE2 - ASQ-3 English

Help Me Grow Hillsborough
[email protected]
http://ecctampabay.org/help-me-grow/

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ:SE-2™ English

Screening Date

I am screening my child today (2024-12-03) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

For ASQ-3™ English

Screening Date I am screening my child today (2024-12-03) I screened my child and am entering in the responses to a previous screening

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. I agree to allow Help Me Grow Florida to enter this data into a secure database in order to follow-up with me on the results of this screening and provide me with other relevant sources.

By completing this screening, you are authorizing the information you provide to be released to/from Help Me Grow partners.

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.