Early Childhood Screening Forms

There are several forms you will need to review or complete prior to your appointment. 

Please read and review the following form sections carefully. If you need forms mailed to you, need an accessible form for your screen reader or other accessibility device, or have questions, please call 952-988-5017.

 


Screening Registration, Consent, and Family Information Forms

Please review these forms, as we will be asking for this information at the appointment. You do not need to complete these forms before your appointment. We would like you to see them in advance so you are familiar with the information that is shared at a screening appointment.

Online Version

Coming Soon

Downloadable Versions

Screening Registration FormPlease have the completed forms available at your scheduled appointment time.

Parent Screening Consent FormPlease have the completed forms available at your scheduled appointment time.

Child Health and Development HistoryPlease have the completed forms available at your scheduled appointment time.

Family Information Form (Optional)This form is optional. However, it can be helpful to know more about family factors that may affect a child’s learning readiness. There may be District resources available to you that could be identified by answering the questions in this form.


Ages and Stages Questionnaire (ASQ 3) Form

Please complete the activities on the "Ages and Stages Questionnaire (ASQ-3)" form (below) before your scheduled appointment time. 

This form has activities for your child to do while you write what you observe. These simple activities provide important developmental information for your child's screening. We will talk about these activities while we meet.

Choose the form that best matches the age your child will be on the date of the screening appointment.

36 months: Form ASQ 3Use this form if your child is 3 years old to 3 years and 2 months old

54 months: Form ASQ 3Use this form if your child is 4 years and 3 months old to 4 years and 8 months old

42 months: Form ASQ 3Use this form if your child is 3 years and 3 months old to 3 years and 8 months old

60 months: Form ASQ 3Use this form if your child is 4 years and 9 months old and older

48 months: Form ASQ 3Use this form if your child is 3 years and 9 months old to 4 years and 2 months old


Ages and Stages Questionnaire (ASQ SE2) Form

Please review these forms, as we will be asking for this information at the appointment. You do not need to complete these forms before your appointment. We would like you to see them in advance so you are familiar with the information that is shared at a screening appointment.

Choose the form that best matches the age your child will be on the date of the screening appointment.

36 months: Form ASQ-SE2Use this form if your child is 3 years old to 3 years and 5 months old

48 months: Form ASQ-SE2Use this form if your child is 3 years and 6 months old to 4 years and 5 months old

60 months: Form ASQ-SE2Use this form if your child is 4 years and 6 months old and older