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WELCOME EASTERSEALS EASTERN PA 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,

Lilibet Perez

Community Outreach Program Manager

• Office 610-289-0114 x232 • Fax 610-796-1954

[email protected]

[email protected]

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

Screening Date

I am screening my child today (03-20-2026) 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 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.