Booking an Ages & Stages Questionnaire (ASQ) Screening Appointment-2025

Booking an Ages & Stages Questionnaire (ASQ) Screening Appointment

(Thank you for your interest in booking an Ages & Stages Questionnaire (ASQ) Screening with a professional from Camino Wellbeing and Mental Health at EarlyON | Roger Street (161 Roger St, Waterloo). The information that you share below will be shared with the professional from Camino Wellbeing and Mental Health you will be meeting with and will also be visible to the EarlyON professionals supporting our booking process. We treat all confidential information with the utmost respect and your information will not be shared beyond with those professionals who require it to support your family and your ASQ screening appointment.)
This ASQ screening appointment must be made and attended by the child’s parent or legal guardian. Please book one time slot per child and complete the form below. An EarlyON team member will connect with you.
Parent/Legal Guardian Name*

First NameLast Name
Parent/Legal Guardian Phone Number*
Please enter a valid phone number.
Parent/Legal Guardian Email*
example@example.com
Parent/Legal Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child Name (Your child is required to be present)*

First NameLast Name
Child Birthdate*

MonthDayYear
Date
Child’s custody status?*

Joint CustodySole CustodyThe Childrens Aid SocietyKinship AgreementNot Applicable- Not separated or DivorcedOther
1. What is your KEyON QR code number? (number on the back of your KEyON tag). If you do not have a KEyON tag, email us at earlyyearsinfo@ytr.ymca.ca to start the process. A KEyON tag is not required to book this screening appointment.
2. I am the parent or legal guardian of the child and will attend the appointment.*

YesNo
If you answered "no" to the above question, you cannot book this consultation appointment. You must be a parent or legal guardian of the child listed above.
3. Which date you would like to book? (Please book a separate appointment for each child)*
4. Do you need an interpreter for your ASQ screening appointment? If yes, what language interpreter do you need?*
5. EarlyON professionals are able to provide childminding for up to two children ages 18 months and up during your appointment if needed. Do you need childminding during your appointment for other children you bring with?*

Yes, I require childminding during my appointment.No, I will not be bringing other child(ren).
If yes, please indicate the names and age(s) of the child(ren) requiring supervision.
Should be Empty: