Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ-3™ English

List others assisting with completion of the questionnaire

We look forward to your participation in our program.  Have fun completing this questionnaire with your child. Please call or email me at any time if you have any questions or would like to discuss any concerns about your child’s development.

Melissa Vandever, Child Development Specialist                                                       

Easterseals Eastern PA                                        

www.easterseals.com/esep

[email protected]

P: 610-289-0114 x230 

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 COMMUNITIES IN SCHOOLS 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 COMMUNITES IN SCHOLS 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

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