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Monument First 5 Center

Welcome to First 5 Monument Center ASQ page. Thank you for taking the time to complete the Ages and Stages Questionnaires on your child that will help us better understand their development and behavior. We hope that it will be a fun process for you and your child. Depending on the age of your child, you may need your child with you to try some of the activities. Please make sure your child is not tired or hungry when trying the activities. We will be sharing the results with you at a later time. If you have any questions about the questionnaires, please talk with Jenny Guerrero.

Child Date of Birth
Format: yyyy-mm-dd

Weeks Premature
(put "0" if not premature)

Screening Date

I am screening my child today (2024-05-02) I screened my child and am entering in the responses to a previous screening

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.

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.