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.

By completing an ASQ developmental screening for your child, you are authorizing verbal and/or written communication between Great Start Livingston, Help Me Grow MI, Early On, and/or the support staff in your school district.  Great Start Livingston and/or Help Me Grow MI will refer your child to Early On (for children 2 months - 2 years/9 months) or to the support person in your school district (for children 2 years/9 months - 5 years) if your child's score indicates a possible area(s) of concern.  Both are free local resources/services.  You will have the opportunity to have a free evaluation for your child and free supports if he/she qualifies.  

Your child's results are confidential and will not be shared outside the Great Start Livingston and Help Me Grow screening project.

Your child's non-identifying information will be combined with others in the program and data will be studied to help improve access to services and supports for all children in the State of Michigan. 

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.