Child Date of Birth
Format: yyyy-mm-dd
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: YYYY-MM-DD

Weeks Premature
(put "0" if not premature)

For ASQ-3™ English

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

By proceeding with this form you agree to allow Help Me Grow Michigan and its affiliates to review your answers. One of our care coordinators will follow up in the next couple of days with your results and activities to support your child's development. With your permission, we may also share your results with your local early childhood support system to ensure your child's needs are met. Your child's non-identifying information will be combined with others in this program, and the data will be studied to help improve access to services for all children in Michigan. 

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