Child Date of Birth
Format: 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)

For ASQ-3™ English

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

The Ages and Stages Questionnaires are being offered by Help Me Grow Washtenaw. Your child's results are confidential.

I give EMU Children's Institute permission to read my child’s screening results and contact me regarding any future supports or resources that would be helpful to giving my child a great start. I also give permission to use my child’s score results in a compiled list to show county data results. The compiled list would not identify my child using his/her name, address, or other specific identifying information.

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.