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 ASQ-3 and I wish to have my child participate in Help Me Grow El Paso's Online Screening Program. I agree to answer questions regarding my child's development and submit my complete responses via the online questionnaire system.

I agree to receive follow-up information from Help Me Grow El Paso regarding screening results and resources to support my child's development. 

If I was referred by my child's pediatrician or child care provider, I understand that results will be shared to support continuity of care.

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