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Tribal Early Education and
Outreach Program

This site is available for parents with children 0-5 to get a snapshot of how their child is developing. The following is a set of developmental screening tools designed and tested to measure how your child is learning and growing. To make the best of these tools, answer as accurately as possible.

All personal information you share is kept private and confidential--it will not be shared with anyone without your expressed consent.

By clicking "Continue" you agree to allow Tribal Early Education and Outreach Program, a program of Northern California Children’s Therapy Center to compile information, resources, and referrals that could benefit your child or family. Later, you will be given the option to choose the care providers with whom you would like us to share the results.
If you would like help to complete this packet, please call 1-855-353-KIDS (5437).

For more information about Tribal Early Education and Outreach Program call 1-855-353-KIDS (5437).

Do you have a completion code?

If you are resuming your data entry from a previous visit to this webpage, enter the code you received in your email after your last data entry session. If you don’t have a completion code, just continue to the question below.

Le dimos una palabra clavel particular (contraseña) para continuar, póngalo aquí:

Have you completed a screening with Tribal Early Education and Outreach Program before?

Yes

The previous screening was completed for:

Same Child

Sibling

That Child's First Name*:

That Child's Last Name*:

That Child's DOB*:

Please enter your current contact information:

Mailing address*:

Mailing address 2:

Mailing city*:

Other city*:

Mailing state*:

Mailing zip*:

Phone number*:

Email address:

We are so sorry that we are unable to find a previous screening matching this record. If you are certain that you have completed a screening with Tribal Early Education and Outreach Program, please contact us via email, Liz.Sardinas@CTCHelpsKids.org, or start a new screening.

Contact Us

Caregiver's Name*:

Child's First Name*:

Child's Last Name*:

Child's DOB*:

Phone number*:

Email address:

Contact form submitted!

En el pasado, usted a completado una encuesta del desarrollo para su hijo/a con Help Me Grow Yolo County?

Sí

Anteriormente usted llenó una encuesta para

el mismo niño/a

el hermano/a

Primer nombre de ese niño/a*:

Apellido de ese niño/a*:

Fecha de nacimiento de ese niño/a*:

Por favor de darnos sus datos corrientes:

Dirección de correo postal*:

Dirección 2:

Ciudad*:

Otra*:

Estado*:

Código postal*:

Teléfono*:

Correo electrónico*:

Desafortunadamente, no podemos localizar una encuesta con este nombre. Si está seguro/a que completó una encuesta con nosotros anteriormente, por favor llámenos gratis al 1-844-410-4769 o mándenos un correo electrónica al information@HelpMeGrowYolo.org.

Contáctenos

Nombre de padre/madre*:

Primer nombre de su hijo/a*:

Apellido de su hijo/a*:

Fecha de nacimiento de su hijo/a*:

Teléfono*:

Correo electrónico*:

Formulario enviado!

Please enter the password provided to you, or contact the Tribal Early Education and Outreach Program at 1-855-353-KIDS (5437).

Por favor entre la palabra clave (contraseña) que se le dimos o por teléfono o por correo electrónico. Si no tiene la palabra clave por favor llame a Help Me Grow Yolo County al 1-844-410-4769 y se la daremos.

Password:

Tribal Early Education andOutreach Program

Contact Us

Contáctenos

Tribal Early Education and
Outreach Program