Brookes ASQ | ASQ:SE2 - ASQ-3 English

Shasta County Office of Education -Early Childhood Services
530-605-2645
[email protected]
43 Hilltop Drive
Redding, California 96003
www.HelpMeGrowShasta.com

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ:SE-2™ English

Screening Date

I am screening my child today (2025-07-15) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

For ASQ-3™ English

Screening Date I am screening my child today (2025-07-15) I screened my child and am entering in the responses to a previous screening

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 and understand that the results will be saved securely in the Help Me Grow Shasta STAR database.

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