How to sign up for ASQ

 

It’s quick, easy, and free to gain access to these tools. Here’s how:

  1. Sign up for Ages & Stages Questionnaires by filling out the form below.
  2. We’ll mail your first Questionnaire, or you can complete the questionnaire online.
  3. Complete the Questionnaire with your child and mail it back.
  4. We’ll send results right away! You’ll also get a FREE BOOK, helpful tips, fun activities and connections to resources.
  5. When it’s time, we’ll send you the next Questionnaire. We’ll keep sending them every few months until your child is 5 1/2.

 

Already enrolled? Complete ASQ online. Click ASQ-3 or ASQ-SE to begin.

Have questions? Learn more by calling 502-292-6159.

 

Get Your Ages & Stages Questionnaire

Please Note… Unfortunately, due to copyright agreements Metro United Way is limited to distributing this tool to residents of our service area in Kentucky and Southern Indiana. We are sorry, but requests completed by residents of other states will not be processed.

If you live outside the Kentuckiana area and you have concerns about your child’s development, try contacting your local school district or your state’s early intervention program.

Thank you for your interest! You have taken the first step to ensure your child has a successful future.

 

  • Are you a resident of Kentucky or the counties of Floyd, Clark or Harrison in Southern Indiana?
  • Would you like to complete the questionnaires on paper or online?
  • Date Format: MM slash DD slash YYYY
  • If the child is was born more than 3 weeks prematurely, please tell us how many weeks early he or she was born.
  • *NOTE: Due to licensing agreements, the ASQ is only available to residents of Kentucky and Southern Indiana. Requests completed by residents of other states will not be processed. If you live outside the Kentuckiana area and you have concerns about your child's development, try contacting your local school district or your state's early intervention program.
  • What county do you live in?
  • Email Address:
  • How did you hear about this opportunity?
  • Please tell us how you identify your child's race.
    *NOTE: For those living in the zip codes of 40203 and 40210, your signature authorizes Metro United Way to share your child's contact information with PLAY COUSINS Collaborative in order to help facilitate your participation in the Developmental Screening Hub. Your child's Ages & Stages Questionnaire results will not be shared with anyone outside of Metro United Way without your consent and will only be used as aggregate data for community level analysis. By clicking submit you are agreeing to enroll your child in the Ages & Stages Monitoring program. Items marked with an asterisk(*) are required

 

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