Help Me Grow Kentucky
275 East Main Street
Frankfort, Kentucky 40621

(put "0" if not premature)

For ASQ-3™ English

For ASQ:SE-2™ English

Your Participation in the Ages & Stages Questionnaires® (ASQ) Means:

Ages & Stages Questionnaires® (ASQ) screenings will be completed on your child’s overall developmental skills. These screens will identify your child’s strengths as well as any areas where your child may need practice or support.

Giving Permission Means:

You freely agree to participate in the ASQ screenings.

Help Me Grow Kentucky will contact you for future screenings.  You can opt out of these future screenings at any time.

You agree to Help Me Grow Kentucky sharing information with your health care provider, First Steps, and/or local school district for referrals to services that may help your child.

Your child’s ASQ results cannot be released to other persons, or programs without your permission.

You always have access to all information collected by Help Me Grow Kentucky about your child.


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.