Brookes ASQ | ASQ:SE2 - ASQ-3 English

MHMR Help Me Grow North Texas
844-689-5437
[email protected]
3840 S Hulen
Ft. Worth, Texas 76017

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 (2024-12-21) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

For ASQ-3™ English

Screening Date I am screening my child today (2024-12-21) 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. 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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