Help Me Grow Kent
118 Commerce Ave. SW
Suite 300
Grand Rapids, Michigan 49503

616-742-8903
www.helpmegrowkent.org

Welcome to our ASQ Online screening program!

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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: Social-Emotional, Second Edition (ASQ:SE-2) to help you keep track of your child's social and emotional development. The questionnaire may be provided for use at 2, 6, 12, 18, 24, 30, 36, 48, or 60 months of age. You will be asked to answer questions about some of your child's behaviors. The 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.

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:SE-2!



(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 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.

Kent County is providing the funding for services to the client through the Ready by Five Millage. 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 in Ready by Five Early Childhood Millage funded services and make referrals. Your relevant data will be shared with the Kent County Health Department, First Steps Kent, and the organization(s) you agree to be referred to.

·       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 by Kent County's Ready by Five Early Childhood Millage to provide this service. Your information will be shared with the Kent County Health Department and First Steps Kent so it can be used for the purposes of community reporting, program quality improvement, and program evaluation. All reports made publicly available to the community will contain only unnamed information about all children in general receiving a millage-funded service. 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

Kent Intermediate School District

1800 Leffingwell Ave NE

Grand Rapids, MI 49525

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.