Monument First 5 Center

You will now be completing the Ages and Stages Social Emotional Questionnaire (ASQ:SE2) on your child.  You will not need your child with you to complete this questionnaire.  If you have any questions about the questionnaires, please talk with Jenny Guerrero.



(put "0" if not premature)


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

Monument First 5 Center 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, 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.