**GESMV COMMUNITY PROGRAM
937-528-6460
b.krise@gesmv.org
660 S Main St
Dayton, Ohio 45402

Welcome to ASQ Online! It's time for a new developmental screening!  

Based on your child’s previous Ages and Stages screening results or the recommended timeline between screenings for your child's age, we're hoping you take a few moments to re-check your child's skills.

Regular developmental screening will help us gather a better developmental picture, make sure your child's development is right on track and/or assist families with any targeted resources to support their child's growth and development. Thank you for taking the time to complete your child’s new questionnaire! 



(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.