Weeks Premature
(put "0" if not premature)

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 Questionnaire, and I wish to have my child participate in the online screening program. I will complete the questionnaire about my child's development and promptly submit it through the Family Access online questionnaire completion system. I understand that the results will be saved securely in the Help Me Grow Shasta Apricot database.

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.