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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,

Melissa Vandever

Child Development Specialist

Easterseals Eastern PA-Lehigh Valley

www.easterseals.com/esep

[email protected]

P: 610-289-0114 x230



MBC - WFMZ - Easterseals Eastern Pennsylvania

Child Date of Birth
Format: yyyy-mm-dd

Weeks Premature
(put "0" if not premature)

Screening Date

I am screening my child today (2024-04-19) I screened my child and am entering in the responses to a previous screening

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.

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 am agreeing to the above 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

*My child’s information will only be shared with other agencies (referral for full evaluation, doctor’s, caretakers, childcare centers, community organization, etc…) with my consent, which I completed here: ESEP Consent

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.