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

After you complete the screening, a Help Me Grow Care Coordinator will follow-up with you by telephone regarding the results. By clicking the “Submit” button below and entering your child's information into the online screening tool, you are agreeing to the following:

 “I authorize this information about my child to be shared with Help Me Grow Yuba County (First 5 Yuba).”

“I authorize Help Me Grow Yuba County to share this information with the affiliated community agencies below, for the purposes of care coordination only. I understand that my child’s information will only be shared if a concern is found and I provide verbal consent for this information to be released to a community agency below.”

 “I acknowledge that I have read and understood the ASQ Family Access End User License Agreement and agree to its terms and conditions.”

“I understand this agreement will be revoked after 1 calendar year, unless otherwise specified in writing.”

If you have any questions or you wish to participate in the developmental screening program without clicking “Submit”, contact Help Me Grow Yuba County at (530)749-4949 or [email protected] for alternative arrangements.

Affiliated Community Agencies:

Yuba County Office of Education, Children’s Home Society, Ampla Health, Alta CA Regional Center, Peach Tree Health, Sutter-Yuba Behavioral Health, Family SOUP, Sutter North Brownsville, Sutter Infant Program, Childcare Planning Council, E Center Head Start, Marysville Pediatric Clinic, Harmony Health, Easter Seals, First 5 Yuba, Yuba County Public Health 

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.