Brookes ASQ | ASQ:SE2 - ASQ-3 English

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https://helpmegrowalabama.org/

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 (2024-11-23) 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 (2024-11-23) 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. 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. We would like to send a copy of the scored questionnaire to your child health care provider. This is a free service and allows you to work interactively with your health care provider so they can offer better care to your family. If you do not wish to receive this service please contact us at the information listed above and we will remove this permission from your file.

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.