GESMV Community Program
660 S Main St
Dayton, Ohio 45402

Welcome to our ASQ Online screening program! The Goodwill Easter Seals Miami Valley Child Screening Program is open to Ohio residents in the 23 Western Ohio counties served through GESMV.

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Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the Ages & Stages Questionnaires, Third Edition (ASQ-3), to help you keep track of your child's development. The questionnaire may be provided every 2-, 4- or 6-month period. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills.

Please enter your child's birth date and the number of weeks he or she was born premature below to start the screening. Please note that the information you enter into this website is secure and cannot be seen or accessed by anyone other than the program employees who have invited you to participate in this screening.

We look forward to your participation in ASQ-3!

(put "0" if not premature)

I am the legal guardian and/or parent of this child.  I have read the provided information about the Ages & Stages questionnaires and I wish to have my child participate in the online screening program. Goodwill Easter Seals Miami Valley (GESMV) Child Screening Team has permission to contact me regarding my child's screening results through email, mail, and/or phone. IN THE EVENT OF A SUSPECTED DELAY OR CONCERN on your child's ASQ-3 Screening, a Goodwill Easter Seals Child Outreach Specialist will attempt to contact you by phone or email to discuss your child's screening and potential options for local assessment services or applicable community resources. GESMV has permission to submit a copy of my child's completed ASQ-3 along with follow-up recommendations to my child's listed pediatrician (if parent provided pediatric contact information and consent during the registration process on this website). *For GESMV Enterprise Child Screening Program Partner sites: Prior to submitting child and caregiver information into the GESMV Enterprise System, the legal guardian and/or parent has granted permission through the GESMV PERMISSION TO SCREEN for our early childhood program to enter screening information.  This PERMISSION TO SCREEN form is available for review by GESMV at any time and is located onsite at my childcare or early childhood program. 

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.