Brookes ASQ | ASQ:SE2 - ASQ-3 English

For questions or information

Klaudia Silva - Bilingual Family Specialist
530-919- 8007 or [email protected]

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ-3™ English

Screening Date

I am screening my child today (2026-04-04) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

Screening Date I am screening my child today (2026-04-04) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

I give consent:

I have read the provided information about the Ages and Stages questionnaires, and I wish to have my child participate in the online screening.

I give consent to the El Dorado County Office of Education (EDCOE)/Community Hub to share the ASQ Questionnaire and results summary with The Gift of Kids.

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