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. If I was referred by a child care center, I understand that my results will be shared with the center. I also understand de-identified results will be compiled and shared with other entities* for evaluative and research purposes. 

**Other Entities may include, but are not limited to:

Early Learning Alliance

Department of State Health Services

Prevention Early Intervention  

My Health My Resources (MHMR) Tarrant County

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.