Child Date of Birth
Format: yyyy-mm-dd
Child DOB you entered is in the future, are you sure of that? (Please correct the date before proceeding to the next step). Please enter your child's DOB and not the screening date or today's date (Please correct the date before proceeding to the next step). Child DOB you entered is not valid, please format the date like this: YYYY-MM-DD

Weeks Premature
(put "0" if not premature)

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

For ASQ-3™ 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. I will fill out the questionnaire about my child's development and promptly submit the completed questionnaire through this Family Access online questionnaire completion system.

To best meet you and your child's needs, Help Me Grow Kent County may be referring you to programs you are interested in.

By providing your consent you understand the following:

·        Help Me Grow Kent will collect demographic information about you and your child.

·        Help Me Grow Kent will have permission to share the information received during your participation to make referrals.

·        The individual information will only be given to the programs that you have said you wish to receive services from.

·        You are giving permission that will allow Help Me Grow Kent to receive updates on your and your child's status of services from programs where you have accepted services.

·        If in any follow-up phone calls or visits with a Help Me Grow Kent representative, you wish to receive additional services that are not accepted on today's date of signed consent, you agree that Help Me Grow Kent may make such referrals based upon your verbal consent.

·        Help Me Grow Kent is receiving funding from Michigan Department of Lifelong Education, Advancement, and Potential (MiLEAP) to provide this service. All reports made publicly available to the community will contain only unnamed information about all children in general. Information specifically about you or your child individually will not be shared without your written permission.

You can cancel this consent form at any time by sending a cancellation request in writing to Help Me Grow Kent at the following address:

Attn: Help Me Grow

Great Start Collaborative of Kent County

118 Commerce Ave. SW

Grand Rapids, MI 49503

Please allow three (3) business days for the cancellation to take effect. This consent is valid until your child reaches six years of age.

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.