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Developmental Screening - Family Follow-Up Form

  1. ASQ results

  2. Instructions

    Please provide us with the following information by typing your responses in the fields below. This should be completed by the parent or caregiver who completed the Ages & Stages Questionnaire.

  3. The purpose of this form is to help us schedule a convenient time to follow-up with you regarding your child's developmental screening results, and any resources you may be interested in receiving.

  4. Please provide us with the best number to reach you at

  5. Your child's results, learning activities, and any follow-up resources will be sent electronically after we have connected with you over the phone.

  6. Please select which day(s) generally work best for you*

    Morning (9:00am - 11:30am) Afternoon (12:00pm - 4:30pm) Evening (4:30pm - 8:00pm)

  7. Our Hours of Operation

    Please note that our daily hours of operation are as follows: Monday-Friday, 8:30am - 4:30pm. We are able to provide an evening follow-up phone call on Tuesdays & Wednesdays from 4:30pm - 8:00pm if a time during the day does not work. **We are not open on statutory holidays.

  8. If you have a specific time during the day that you would like us to call you can enter it here, for example 3:15pm on Monday

  9. We look forward to connecting with you!

    You can expect one of our team members to connect with you within 24-48 hours after completing an ASQ.

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  12. Leave This Blank:

  13. This field is not part of the form submission.