Brookes ASQ | ASQ:SE2 - ASQ-3 English

Spartanburg Academic Movement
349 E Main St Suite 101
Spartanburg, South Carolina 29302

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

Questionnaires should be completed by the child's parent or legal guardian.

By proceeding with this form, you agree to allow Help Me Grow South Carolina to review your answers and use your information as is consistent with our Privacy Policy and Consent to Use of Data, which is posted on our website: https://helpmegrowsc.org/privacy/.

In addition, we would like to send a copy of the scored questionnaire to your child's health care provider. This is a free service, and allows you to work interactively with your health care team so they can offer better care to your family. We also may share screening results with your child care provider upon their request if your child is being screened through a partnership between your child care provider and Help Me Grow South Carolina. If you do not wish your child’s scores to be shared, please contact us at [email protected], and we will remove these permissions 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.