Brookes ASQ | ASQ:SE2 - ASQ-3 English

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Welcome Family of Pediatric Neurology of Lehigh Valley! You are about to access our ASQ Online screening and monitoring program!

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ:SE-2™ English

Screening Date

List others assisting with completion of the questionnaire

For ASQ-3™ English

Screening Date

List others assisting with completion of the questionnaire

Consent

*I have read the provided information about the MtFFC screenings. I wish to have my child participate in the screening and monitoring program.

*I have read, understand, and agree to the online consent. Please complete the consent here if you haven’t already: ESEP consent with PNLV

*I have received a copy of the HIPAA statement: ESEP HIPAA

*I agree to be contacted by an Easterseals specialist, who will share the results with me and also give me activities and/or connect you to community resources in line with my child’s individual needs.

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.