Shifa Clinic
668 Marina Drive
Suite A-5
Charleston, South Carolina 29492

(put "0" if not premature)

Screening Date Options

For ASQ-3™ English

Screening Date Selection

For ASQ:SE-2™ English

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.

In addition, I agree to allow Help Me Grow South Carolina to review my answers and use my information as is consistent with their Privacy Policy and Consent to Use of Data, which is posted on their website:

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.