Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

Consent Form -- Please Read Carefully:

You/your child must live in Yolo County to participate.

By giving my consent, I understand that my child’s data will be shared with:

First 5 Yolo for program evaluation, quality improvement, and program administration

Northern California Children's Therapy Center, Help Me Grow Yolo Lead Service Provider

My provider/program

I understand that:

First 5 Yolo's Help Me Grow network providers never use names or identifying information when reporting summary information to partners or funders.

My consent can be revoked at any time by contacting the organization providing my child’s developmental/behavioral screening and/or Help Me Grow Yolo

My provider (indicated below) or a Help Me Grow Yolo Child Development Specialist will only contact me to discuss results and assist me with follow up to needed services or offer me services for which I may be eligible.

My permission is required to share my information with anyone else.

Copyright note: Please do not save or distribute blank copies of the ASQ, or use it for commercial purposes. These actions violate the copyright. Thank you for your cooperation!

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.