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WELCOME WHITEHOUSE DAY CARE CENTER FAMILY! YOU ARE ABOUT TO ACCESS OUR ASQ ONLINE SCREENING PROGRAM!

Select a time your child is happy, alert, and ready to play. Make it a game and you’ll both have fun! If completing this questionnaire brings up any questions or concerns, please don’t hesitate to contact me.

Regards,

Christina Reilley

Make the First Five Count Coordinator

Easterseals Eastern PA

www.easterseals.com/esep

[email protected]

P: 610-289-0114 x232

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

Screening Date

I am screening my child today (08-26-2025) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

CONSENT TO SHARE MY CHILD'S INFORMATION AND FOLLOW UP:

*I have read the provided information about the MtFFC screenings. I wish to have my child participate in the screening and monitoring program. I am agreeing to the below statements, by completing the ASQ-3 and ASQ:SE-2 questionnaires.

*I hereby authorize WHITE HOUSE DAYCARE CENTER to release and/or share any necessary information with Easterseals Eastern Pennsylvania throughout the school year.

*I hereby authorize Easterseals Eastern Pennsylvania to release and/or share results and any information necessary information with WHITE HOUSE DAYCARE CENTER throughout the school year.

*I agree to be contacted by an Easterseals Specialist, who will share the results with me and also give me activities and/or as needed connect me to community resources in line with my child’s individual needs. CLICK HERE TO SEE EASTERSEALS EASTERN PA'S HIPAA STATEMENT

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.