Brookes ASQ | ASQ:SE2 - ASQ-3 English

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2-1-1 Palm Beach/Treasure Coast
P.O. Box 3588
Lantana, Florida 33465

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ-3™ English

Screening Date

I am screening my child today (2024-11-21) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

Screening Date I am screening my child today (2024-11-21) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

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

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.

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