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

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By proceeding with this questionnaire, you agree to allow Help Me Grow Maine to review your answers and follow up with you directly. Help Me Grow Maine will communicate screening results and other basic information about your family with your child’s health care provider and other service providers. When appropriate, a copy of the scored questionnaire in full will be shared with your child’s health care or other service provider to improve support for your family.

Additionally, Help Me Grow Maine shares developmental screening information with others to provide an overall view of how Maine children are doing and to coordinate support. By clicking “Submit” you are agreeing to share your child’s information and screening results as outlined in the Authorization for Release. This authorization is voluntary.

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.