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First 5 Siskiyou Children and Families Commission

Phone: 530.918.7222

https://first5siskiyou.org/help-me-grow-siskiyou/

Welcome to our Ages and Stages Questionnaire (ASQ) Online screening program!

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, Third Edition (ASQ-3), to help you keep track of your child's development. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills. It is common to have some actions your son/daughter can do and some they cannot. Our goal is to identify their strengths and see where we can support with a little more work at home or with some community resources.

Once you complete the survey one of our team members will reach out to you to discuss your childs development and see if you have any questions. Through this program we can provide fun games to play, activities you can your child can do together and community offerings that may support additional needs. Thank you for taking the time and dedication in supporting your child!

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.

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

Screening Date

I am screening my child today (05-09-2025) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

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 by completing the Ages and Stages Questionnaire I am giving consent for my child's results to be shared with their preschool teacher or child care provider upon their request.

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.

First 5 Siskiyou Children and Families Commission Phone: 530.918.7222 https://first5siskiyou.org/help-me-grow-siskiyou/

First 5 Siskiyou Children and Families Commission

Phone: 530.918.7222

https://first5siskiyou.org/help-me-grow-siskiyou/