Child Date of Birth
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: MM-DD-YYYY

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 understand that my results and information will be shared with the referring entity and Help Me Grow Bexar County. I also understand de-identified results will be compiled and shared with other entities* for evaluative and research purposes.

 

*Other Entities may include, but are not limited to: United Way of San Antonio and Bexar County, Texas Department of State Health Services, Texas Health and Human Services, and Help Me Grow National Center.