Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ-3™ English

List others assisting with completion of the questionnaire

After you complete the screening, a Help Me Grow Care Coordinator from First Five Yuba will follow up with you by telephone regarding the results.

By clicking “Submit” and entering your child’s information into the online screening tool, you acknowledge and agree to the following:

Program Participation & Release of Liability
I understand that participation in First Five Yuba programs and services is voluntary. I am responsible for decisions regarding my and/or my child’s participation and the appropriate use of information, resources, materials, or items provided. First Five Yuba is not responsible for services provided by outside organizations or providers. I release First Five Yuba from liability related to participation in First Five Yuba programs, services, or activities, to the extent permitted by law.

Use of Information & Privacy
I authorize First Five Yuba to use and maintain information about me and/or my child to provide services, maintain program records, coordinate care and referrals, evaluate and improve programs, and handle billing when applicable. My information will be kept private and confidential as required by law. Evaluation results are reported in summary form and will not identify individual children or families.

Billing
First Five Yuba services are provided at no cost to me and/or my child. When applicable, First Five Yuba may bill Medi-Cal for eligible services and share information necessary for billing and payment. I will never receive a bill, and First Five Yuba does not bill private insurance.

Sharing Information
First Five Yuba will obtain additional consent before sharing identifiable information about me and/or my child with another organization or service provider, except as needed for billing and payment. If I live outside Yuba County, I authorize First Five Yuba to send my child’s screening and contact information to the Help Me Grow program or appropriate agency serving my county so they can follow up with me.

Photos & Videos-only applicable if attending in-person First 5 Yuba Events
When participating in First Five Yuba programs or activities in person, photos or videos may be taken for program documentation, improvement, social media, or promotional materials. Names will not be included with photos shared publicly. I may tell First Five Yuba staff if I do not want myself and/or my child included.

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

I understand that this authorization expires after one calendar year unless otherwise specified in writing.

By clicking “Submit,” I agree to participate in First Five Yuba programs and services and authorize First Five Yuba to use my and/or my child’s information as described above.

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

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.