Kidsource Therapy - SCREENER
501-315-4414
[email protected]
www.kidsourcetherapy.com

Welcome to our ASQ Online screening program!

View description Hide description

Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the Ages & Stages Questionnaires, Third Edition (ASQ-3), to help you keep track of your child's development. The questionnaire may be provided every 2-, 4- or 6-month period. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills.

Please enter your child's birth date and the number of weeks he or she was born premature below to start the screening. Please note that the information you enter into this website is secure and cannot be seen or accessed by anyone other than the program employees who have invited you to participate in this screening.

We look forward to your participation in ASQ-3!



(put "0" if not premature)



I have read the provided information about the Ages & Stages questionnaires, and I wish to have my child participate in the developmental screening program provided by Kidsource Therapy.

By providing information about my child's development in this Family Access online system, I consent to allow Kidsource Therapy to complete a free developmental screening. I understand all information provided and obtained during the screening process is considered confidential, protected health information.

I understand that if the ASQ-3 screening results show a possible delay in any area, my child will be referred to the Arkansas First Connections Early Intervention program (ages birth-3) or the Educational Cooperatives (ages 3-5), where I will have the opportunity for additional assessments, at no cost to my family.

I understand I may revoke consent at any time by emailing [email protected] or in writing to: Kidsource Therapy, Inc. at 17706 I-30 Suite 3 in Benton, AR 72019.

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.