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 Ages & Stages questionnaires, and I wish to have my child participate in the online screening program.  By completing the online screening you are providing consent for screening results to be shared with your child's pediatrician.  I  understand that the results will be saved securely in the Help Me Grow Butte STAR database and consent to receive follow-up from the Help Me Grow Care Coordinator. 

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