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:SE-2™ English

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 will follow-up with via telephone regarding the results. Please note that by clicking “Submit” and entering your child's information into the online screening tool you are consenting to Help Me Grow Yuba County (First 5 Yuba) receiving and reviewing this information.  This information may also be shared with the affiliated community agencies below, for the purposes of care coordination only. Your child’s information will only be shared if a concern is found and you provide verbal consent for this information to be released to a community agency below. If you have any questions or you wish to participate in the behavioral screening program without clicking “Submit” below, contact Help Me Grow Yuba County at (800) 794-4067 or helpmegrowyubacounty.com for alternative arrangements. Please contact us during the screening if you have questions, want additional information on Help Me Grow, or need assistance filling out the screen.

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.