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

What Happens Next?

Once you submit the ASQ, you will receive feedback by email within one week to celebrate your child’s developmental milestones. You will also find fun learning activities and games on the thank-you page that you can enjoy with your child to support their growth and learning.

If you express any concerns or your child’s screening results indicate a possible developmental concern, the Help Me Grow Coordinator will discuss possible next steps, resources, and support options with you.

Thank you for participating in the ASQ and supporting your child’s development!

Parent/Guardian Consent and Permission to Share Information

By completing the ASQ online, I give permission for the Help Me Grow Coordinator to review my child’s screening responses, score the questionnaire, and provide me with feedback about my child’s developmental progress.

I understand and agree that my child’s ASQ screening results and related information may be shared, as appropriate, with my child’s childcare provider or early learning program, the West Shore Educational Service District (WSESD) support team, my child’s physician or healthcare provider, and other appropriate early childhood, developmental, educational, or support professionals involved in supporting my child. Information may be shared to coordinate services, address developmental concerns, identify appropriate resources, and support my child’s growth and learning.

I understand that information will be shared for these purposes and handled in accordance with applicable privacy requirements. I authorize the sharing of relevant screening information as described above.

Information collected through the ASQ may also be used in aggregate to better understand the developmental needs of young children in our community and to help guide local programs, services, and resources.

By submitting the ASQ, I acknowledge that I have read and understand this consent and give permission for the use and sharing of my child’s information as described above.

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.