{Help Me Grow North Texas}844-689-5437[email protected]3840 S HulenFt. Worth, Texas 76017
Child Date of BirthFormat: yyyy-mm-dd Child DOB you entered is in the future, are you sure of that? (Please correct the date before proceeding to the next step). Please enter your child's DOB and not the screening date or today's date (Please correct the date before proceeding to the next step). Child DOB you entered is not valid, please format the date like this: YYYY-MM-DD
Weeks Premature (put "0" if not premature)
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
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