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

·  Monument First 5staff, a representative from First 5 Contra Costa, and possibly other center partners may review my child’s completed ASQ3 and ASQ: SE2.

·  Monument First 5 staff and First 5 Contra Costa will include only my child’s screening scores, birthdate, and child’s initials in an aggregate report on screening and referrals in Contra Costa County. Total number of children screened will be provided to First 5 Contra Costa County, but no identifying information will be shared.

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.  

You and your child’s personal information will be kept confidential and will not be shared or sold.

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.

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.