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

I have read the provided information about the Ages & Stages questionnaires, and I wish to have my child participate in the online screening program. I will fill out the questionnaire about my child's development and promptly submit the completed questionnaire through this Family Access online questionnaire completion system. 

Results of the Ages & Stages Questionnaires (ASQ-3) will be sent within 10 business days to the email address you provide through this registration process. 

The Ages & Stages Questionnaires (ASQ-3) are designed for children birth through age five. If your child is age six or more, please discuss his or her development with your child's health care provider, your local school district, or your child's teacher. 

By clicking submit, you acknowledge that you have read the provided information about the Ages & Stages Questionnaires (ASQ-3), will complete the questionnaires regarding your child’s development and will return the completed questionnaires via the online questionnaire completion system. 

You also agree to receive information from Community Options relative to the results of the screening as well as periodic information about our work. 

 If you are completing this questionnaire on behalf of a child's parent or legal guardian, you must have their permission to do so. 

Completing these questionnaires does not guarantee a full assessment - these are tools we use to determine if further assessment is an appropriate course of action for your child. 

By clicking submit you acknowledge and agree to these terms. 

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.