Brookes ASQ | ASQ:SE2 - ASQ-3 English

First 5 Siskiyou Children and Families Commission

Phone: 530.918.7222

https://first5siskiyou.org/help-me-grow-siskiyou/

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ-3™ English

Screening Date

I am screening my child today (2024-11-21) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

Screening Date I am screening my child today (2024-11-21) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

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.

I understand that by completing the Ages and Stages Questionnaire I am giving consent for my child's results to be shared with their preschool teacher or child care provider upon their request.

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.