Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ-3™ English

List others assisting with completion of the questionnaire

By proceeding with this questionnaire, you agree to allow Help Me Grow Vermont (HMGVT) to review your answers and follow up with you directly. HMGVT will communicate screening results and other basic information about your family with your child’s health care provider and other service providers. If appropriate, a copy of the scored questionnaire in full will be shared with your child’s health care or other service provider to improve support for your family.

Additionally, HMGVT shares developmental screening information with others through the Vermont Department of Health’s Developmental Screening Registry to provide an overall view of how Vermont’s children are doing and to coordinate support. By clicking “Submit” you are agreeing to share your child’s information and screening results as outlined in the Authorization for Release and Disclosure of Developmental Screening Results. This authorization is voluntary.

For more details, or if you do NOT wish to participate in this online developmental screening program, please contact us.

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.