High County Early Intervention
928-776-9285
[email protected]
3160 Stillwater Dr
Prescott, Arizona 86305
www.hceip.org

Welcome to our ASQ Online screening program!  By completing a screening on your child, not only will you learn what is typical development at your child's age, you will also receive a listing of age-appropriate activities that you can do at home to support your child's development.  Within a week, you will receive a phone call to review your child's results, answer any questions that you have, and learn about free community resources that can help you to support your child's development.

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Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the Ages & Stages Questionnaires: Social-Emotional, Second Edition (ASQ:SE-2) to help you keep track of your child's social and emotional development. The questionnaire may be provided for use at 2, 6, 12, 18, 24, 30, 36, 48, or 60 months of age. You will be asked to answer questions about some of your child's behaviors. The questionnaire includes questions about your child's ability to calm down, take direction and follow rules, communicate, perform daily activities (e.g., eating, sleeping), act independently, demonstrate feelings, and interact with others.

Please enter your child's birth date and the number of weeks he or she was born premature below to start the screening. Please note that the information you enter into this website is secure and cannot be seen or accessed by anyone other than the program employees who have invited you to participate in this screening.

We look forward to your participation in ASQ:SE-2!



(put "0" if not premature)


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.  I understand that my child's records will not be released to anyone without my written consent on the Release of Information/Authorization for Use of Disclosure of Protected Health Information (in accordance with Arizona state law, the Privacy Rule of the Health Insurance Portability and Accountability Act of 1986 (HIPAA) and 42 CFR Part 2).  I understand that my child's records will be kept for 5 years and then they will be destroyed

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.

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