Help Me Grow Utah
148 W 100 N
Provo, Utah 84601

ASQ SE: Social Emotional Development Screening

Welcome to Help Me Grow Utah, an initiative of United Way of Utah County and partnering with all United Ways of Utah!

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 ASQ program, to help you keep track of your child's development.  In addition to connecting you to the ASQ, we will also work with you to identify resources, programs and information that are right for your family.

The ASQ:SE is an online developmental screening tool that helps you to:

This social-emotional questionnaire will be provided yearly, but may be completed more often if desired. You will be asked to answer questions about things your child can and cannot do at this time. The questionnaire includes questions that focus on your child's social-emotional skills and behavior.

This developmental screening opportunity is provided by Help Me Grow Utah. We look forward to working with you to provide the best start to your child’s life! 

To get started with the ASQ:SE Online Questionnaire, please enter your child's birth date and the number of weeks he or she was born premature below to start the screening. 

(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.

I am the parent or legal guardian of this child with authority to make healthcare decisions for my child. By clicking submit, I agree to allow data entered through this electronic form to be stored in a secure database for my provider to review.

If I choose not to submit this and share my child’s screening data as stated above, I may request a paper screening option from my child’s provider.

I understand that signing this authorization is voluntary. I understand this authorization will expire upon my child's 18th birthday. I understand that I may revoke this authorization at any time and the revocation does not apply to any action that has taken place prior to the date I revoke this authorization. To revoke this authorization, I must make a request in writing and send it to: Subject Line: REVOCATION.

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.