Butler Early Access Network
316-775-5491 x4
520 E Augusta Ave
South Central Mental Health

Welcome to the Ages and Stages Questionnaire Social Emotional provided by Butler Early Access Network (BEAN)! This short screen will give you a snapshot at your child's social-emotional readiness.  BEAN's mission is to promote universal social-emotional awareness across Butler County. BEAN is also a referral and resource hub for parents of children 0-6 and can provide assistance with referrals to community services and resources.

View description Hide description

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 give permission for the screening organization to speak with the programs checked above and to share my contact information with other programs that may be able to help my family.

South Central Mental Health Counseling Center (SCMHCC) has purchased access to a web-based data management system, ASQ Online. To facilitate coordination and sharing of information between early childhood partners at the local level, partners have established a single ASQ Online account. This agreement describes the sharing of data between these local partners.

 

Purpose

Early childhood system partners are collaborating to coordinate, improve, and track developmental screenings and referrals for infants and toddlers in Butler County. It is important to show how well programs and systems are helping children and their families in Butler County, and it is important to show that the programs and systems improve children’s readiness for school over time. This can only be done by getting information from children and families in these programs over time.

 

Data

“Data” is personally identifiable demographic information as well as information derived from a series of questions assessing the behavior and communication skills of children and is used to identify signs of developmental delay.

 

How Your Data May be Used

By signing this agreement, You understand the Data you share will be available to project members of the Butler Early Access Network (BEAN) at South Central Mental Health, and will be shared with early childhood partners through the Butler Early Childhood Task Force: BEAN Referral Committee.  The agreement requires informed consent from parents or legal guardians in order for data to be used by BEAN/SCMHCC and the BEAN Referral Committee:

 

  1. To track children birth to five for their risk factors, referrals, programs attended, screening results, and, ultimately, kindergarten readiness.

  2. To generate summary level reports for sharing with local early childhood partners for purposes of continuous quality improvement of programs and services.

  3. To generate summary level reports that can be shared with current and potential funders, such as the Department for Children and Families (DCF), Kansas Children’s Cabinet and Trust Fund (KCCTF), Kansas Department of Education (KSDE), and Kansas Department of Health and Environment (KDHE) at the state level.

  4. To coordinate and refer to services and programs in the community upon review of Data from the Butler Early Childhood Task Force: BEAN Referral Committee members. Child information will be reviewed and parent/guardian contacted by BEAN representative to assist with potential referral to services and/or resources.

     

    Protection of Data

  1. Information from your forms will be entered into an electronic database, the ASQ Online. The ASQ Online is safe, secure, and password protected. You will be asked to put your name and your child’s name on the forms.

  2. SCMHCC/BEAN will ensure that all programs and employees with access to your Data understand and acknowledge the confidentiality of program data and the trust and confidence You have placed in them by providing access and contact to this information. 

  3. SCMHCC/BEAN will exercise the utmost diligence to protect and safeguard your confidential and proprietary information, as well as personally identifiable client level information.

  4. SCMHCC/BEAN will notify you within ten days upon discovering any breach or suspected breach of security or of any disclosure of the data to any unauthorized individual or entity.

  5. SCMHCC/BEAN agrees to use and access ASQ Online solely for the purposes stated in this Agreement.

  6. SCMHCC/BEAN and early childhood partners will safeguard all personal health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

     

    Refusal/Withdrawal

    You do not have to complete the forms if you do not want to. Your decision whether or not to help with the research, and decision to participate in follow-up services will NOT affect your future relationships with early childhood partners, SCMHCC/BEAN, or the program(s) your child is in. You are free to skip any question or quit at any time.

     

    Term and Termination

  1. You may be asked to complete this consent form each time you or your child enters a new early childhood program, or upon each time this screen is taken at six-month intervals.

  2. You have the right to discontinue information sharing by making your child’s profile “inactive” at any time by contacting the screening organization or the program your child is enrolled in.

     

    Contact

    If you have any questions about the BEAN program or research, you can contact Holly Whitson of the SCMHCC/BEAN Project Coordinator at 316.775.5491 x4 or hollywhitson@scmhcc.org.  You can also call the United Way’s 211 for additional resources.

 

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.