Early Childhood Council of Hillsborough County
4210 West Bay Villa Avenue
Tampa, Florida 33611
http://ecctampabay.org/help-me-grow/



(put "0" if not premature)

For ASQ:SE-2™ English

For ASQ-3™ 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. I agree to allow Help Me Grow Florida to enter this data into a secure database in order to follow-up with me on the results of this screening and provide me with other relevant sources.

By completing this screening, you are authorizing the information you provide to be released to/from Help Me Grow partners. 

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.