Brookes ASQ | ASQ:SE2 - ASQ-3 English

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Addison Northwest School District
802-382-0045
[email protected]
11 Main St. Suite B100
Vergennes, Vermont 05491
https://mbaker61.wixsite.com/uprek

The ASQ-3 questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills. This questionnaire is highly recommended.

The ASQ-SE questionnaire includes questions about your child's ability to calm down, take direction and follow rules, communicate, perform daily activities (e.g., eating, sleeping), act independently, demonstrate feelings, and interact with others.

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 (2024-12-04) 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 (2024-12-04) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

I consent for the school district to share the results of this screening with my child's preschool program. Screening results will be used to help tailor the preschool curriculum to best support my child.

By proceeding with this questionnaire, you agree to allow Addison Northwest School District to review your answers and follow up with you directly. Addison Northwest School District will communicate screening results and other basic information about your family with other service providers when appropriate.

Additionally, in partnership with Help Me Grow Vermont, Addison Northwest School District shares developmental screening information with others to provide an overall view of how Vermont’s children are doing and to coordinate support. By clicking “Submit” you are agreeing to share your child’s information and screening results as outlined in the Authorization for Release and Disclosure of Developmental Screening Results. This authorization is voluntary.

For more details, or if you do NOT wish to participate in this online developmental screening program, please contact us.

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.